Provider Demographics
NPI:1538145834
Name:LIPMAN, DEREK SPENCER (MD, LTD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:SPENCER
Last Name:LIPMAN
Suffix:
Gender:M
Credentials:MD, LTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10662207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR154963Medicaid
C93160Medicare UPIN
OR154963Medicaid