Provider Demographics
NPI:1780677732
Name:LIPSCOMB, DIANE C (MD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:C
Last Name:LIPSCOMB
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1235 E CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2203
Practice Address - Country:US
Practice Address - Phone:417-829-5400
Practice Address - Fax:417-820-7129
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20120347472080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1780677732Medicaid
AR195052001Medicaid
MO431560263OtherTRICARE
MOP01116103OtherRR MCR
OK200209400 AMedicaid
AR195052001Medicaid