Provider Demographics
NPI:1013900281
Name:TIPPIN, DOUGLAS B (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:B
Last Name:TIPPIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 COLONIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1410
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:2222 N NEVADA AVE STE CC101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-6819
Practice Address - Country:US
Practice Address - Phone:719-776-5281
Practice Address - Fax:719-776-2525
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40881174400000X
CAC1547532085R0001X
COCDRH.00408812085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04004909Medicaid
COCB2808Medicare ID - Type Unspecified
CO04004909Medicaid