Provider Demographics
NPI:1336297001
Name:KIPP, MARTIN V (OD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:V
Last Name:KIPP
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 COLONIE CENTER
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-437-0287
Mailing Address - Fax:518-437-9690
Practice Address - Street 1:449 COLONIE CENTER
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-2754
Practice Address - Country:US
Practice Address - Phone:518-437-9633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNY4427152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU32135Medicare UPIN
NYCC8833Medicare ID - Type Unspecified