Provider Demographics
NPI:1558533620
Name:TIPTON, JAMES DAVIS JR (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:DAVIS
Last Name:TIPTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JIMMY
Other - Middle Name:
Other - Last Name:TIPTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4420 DIXIE HWY STE 126
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2994
Practice Address - Country:US
Practice Address - Phone:502-810-3780
Practice Address - Fax:502-394-3607
Is Sole Proprietor?:No
Enumeration Date:2008-03-29
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY44052208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY135332OtherSIHO - NICC
KYK043420OtherMEDICARE - NICC
KY000000765950OtherANTHEM - NICC