Provider Demographics
NPI:1659597284
Name:LIPPOLD, SUSAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LIPPOLD
Suffix:
Gender:F
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:P.O. BOX 4000
Mailing Address - Street 2:HOPI HEALTH CARE CENTER/KEAMS CANYON S.U.
Mailing Address - City:POLACCA
Mailing Address - State:AZ
Mailing Address - Zip Code:86042
Mailing Address - Country:US
Mailing Address - Phone:928-737-6000
Mailing Address - Fax:
Practice Address - Street 1:HWY 264, MP 388
Practice Address - Street 2:HOPI HEALTH CARE CENTER
Practice Address - City:POLACCA
Practice Address - State:AZ
Practice Address - Zip Code:86042
Practice Address - Country:US
Practice Address - Phone:928-737-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-102153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH59547Medicare UPIN
ILPHS0000Medicare UPIN