Provider Demographics
NPI:1336190016
Name:LIPTON, GLENN M (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:M
Last Name:LIPTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:989 S MAIN ST
Mailing Address - Street 2:SUITE A-613
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4601
Mailing Address - Country:US
Mailing Address - Phone:928-649-7999
Mailing Address - Fax:
Practice Address - Street 1:294 W STATE ROUTE 89A
Practice Address - Street 2:SUITE 110
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-3754
Practice Address - Country:US
Practice Address - Phone:928-649-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32683208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ110516Medicare PIN