Provider Demographics
NPI:1922065598
Name:TIPTON, MARY D (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:D
Last Name:TIPTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3556 W 9800 S
Mailing Address - Street 2:#101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-3211
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:801-352-9502
Practice Address - Street 1:3556 W 9800 S
Practice Address - Street 2:#101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-3211
Practice Address - Country:US
Practice Address - Phone:801-352-9500
Practice Address - Fax:801-352-9502
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT5934303-1205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005596706Medicare PIN
UTI28288Medicare UPIN