Provider Demographics
NPI:1437150083
Name:LIPSEN, BRYAN C (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:C
Last Name:LIPSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BRYAN
Other - Middle Name:C
Other - Last Name:LIPSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:509 W TIDWELL RD STE 314
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77091-4354
Mailing Address - Country:US
Mailing Address - Phone:731-635-6996
Mailing Address - Fax:713-635-6994
Practice Address - Street 1:509 W TIDWELL RD
Practice Address - Street 2:SUITE 314
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77091-4352
Practice Address - Country:US
Practice Address - Phone:713-635-6996
Practice Address - Fax:713-635-6994
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-04
Last Update Date:2021-02-25
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
TXJ8034207R00000X, 207RI0008X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3766622OtherAETNA
TX127602408Medicaid
TX171704301Medicaid
TX10021896Medicaid
TX171704301Medicaid
TX10021896Medicaid
TX127602408Medicaid