Provider Demographics
NPI:1366484990
Name:FRIPP, VIKISHA TYESE (MD)
Entity Type:Individual
Prefix:DR
First Name:VIKISHA
Middle Name:TYESE
Last Name:FRIPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 VARNUM ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20017-2104
Mailing Address - Country:US
Mailing Address - Phone:202-448-4080
Mailing Address - Fax:202-448-4082
Practice Address - Street 1:1150 VARNUM ST NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20017-2104
Practice Address - Country:US
Practice Address - Phone:202-448-4080
Practice Address - Fax:202-448-4082
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057460207Q00000X, 208200000X
DCMD039256208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA057460OtherGA MEDICAL LICENSE
DCMD039256Medicaid
GA511I020024Medicare PIN
GA511G7000201Medicare PIN