Provider Demographics
NPI:1568597235
Name:MARK DAVID LIPETZ
Entity Type:Organization
Organization Name:MARK DAVID LIPETZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:LIPETZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-891-1177
Mailing Address - Street 1:41 E LIPOA ST STE 22
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8148
Mailing Address - Country:US
Mailing Address - Phone:808-891-1177
Mailing Address - Fax:808-891-2255
Practice Address - Street 1:41 E LIPOA ST STE 22
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-8148
Practice Address - Country:US
Practice Address - Phone:808-891-1177
Practice Address - Fax:808-891-2255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI10263261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH100089Medicare PIN
HIG77170Medicare UPIN