Provider Demographics
NPI:1497787600
Name:LIPPA, GINA MARIE (OPTICIAN)
Entity Type:Individual
Prefix:MISS
First Name:GINA
Middle Name:MARIE
Last Name:LIPPA
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:MRS
Other - First Name:GINA
Other - Middle Name:MARIE
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OPTICIAN
Mailing Address - Street 1:300 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1118
Mailing Address - Country:US
Mailing Address - Phone:585-637-3905
Mailing Address - Fax:585-637-4990
Practice Address - Street 1:300 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1118
Practice Address - Country:US
Practice Address - Phone:585-637-3905
Practice Address - Fax:585-637-4990
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006495-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1598707812OtherOAK ORCHARD BROCKPORT NPI
NY179014CTOtherPREFERRED CARE VENDOR #
NY17209159OtherEXCELLUS VENDOR #