Provider Demographics
NPI:1497928303
Name:DEREK S. LIPMAN MD LTD
Entity Type:Organization
Organization Name:DEREK S. LIPMAN MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:S
Authorized Official - Last Name:LIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-675-6776
Mailing Address - Street 1:17704 JEAN WAY
Mailing Address - Street 2:STE 105
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-5497
Mailing Address - Country:US
Mailing Address - Phone:503-675-6776
Mailing Address - Fax:503-675-2572
Practice Address - Street 1:17704 JEAN WAY
Practice Address - Street 2:STE 105
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-5497
Practice Address - Country:US
Practice Address - Phone:503-675-6776
Practice Address - Fax:503-675-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154963Medicaid
OR154963Medicaid