Provider Demographics
NPI:1558639666
Name:IP, STEPHEN
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:
Last Name:IP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-2105
Mailing Address - Country:US
Mailing Address - Phone:201-599-0713
Mailing Address - Fax:
Practice Address - Street 1:406 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:DUMONT
Practice Address - State:NJ
Practice Address - Zip Code:07628-2629
Practice Address - Country:US
Practice Address - Phone:201-384-8942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-02
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5201-0701-0125-544183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician