Provider Demographics
NPI:1710231600
Name:PIPPEN, ELLIOTT BENNETT (IDC)
Entity Type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:BENNETT
Last Name:PIPPEN
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1804 GRAVENHURST DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8656
Mailing Address - Country:US
Mailing Address - Phone:757-373-9095
Mailing Address - Fax:
Practice Address - Street 1:1804 GRAVENHURST DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8656
Practice Address - Country:US
Practice Address - Phone:757-373-9095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman