Provider Demographics
NPI:1518940832
Name:LIPOVITCH, FRED BARNETT (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:BARNETT
Last Name:LIPOVITCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16623 N 59TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-1251
Mailing Address - Country:US
Mailing Address - Phone:602-293-3550
Mailing Address - Fax:
Practice Address - Street 1:625 N PLAZA DR
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85120-5501
Practice Address - Country:US
Practice Address - Phone:480-983-0065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ56722084P0802X, 2084P0804X, 2084P0805X, 2084H0002X, 2084P0005X, 2084P0800X, 2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine
No2084P0005XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurodevelopmental Disabilities
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237231Medicaid
AZ237231Medicaid
INC99883Medicare UPIN