Provider Demographics
NPI:1275716847
Name:LIPSTOCK, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LIPSTOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 WESTERRE PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-1326
Mailing Address - Country:US
Mailing Address - Phone:804-288-1543
Mailing Address - Fax:804-285-2375
Practice Address - Street 1:3701 WESTERRE PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-1326
Practice Address - Country:US
Practice Address - Phone:804-288-1543
Practice Address - Fax:804-285-2375
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-06
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101030447207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6398821Medicaid
VA6398821Medicaid