Provider Demographics
NPI:1639100845
Name:LIPHAM, JOHN CLARENCE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLARENCE
Last Name:LIPHAM
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:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-9062
Mailing Address - Fax:
Practice Address - Street 1:1450 SAN PABLO ST STE 6200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033
Practice Address - Country:US
Practice Address - Phone:323-442-9062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62161208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020048357OtherMEDICARE RAILROAD PIN
CA00A621610OtherBLUE SHIELD PIN
CA00A621610Medicaid
CA00A621610C29OtherCAL OPTIMA PIN
CA00A621610C29OtherCAL OPTIMA PIN
CAH29788Medicare UPIN
CABM860ZMedicare PIN