Provider Demographics
NPI:1477931244
Name:TIPPETS, TREVOR WOOD (DPM)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:WOOD
Last Name:TIPPETS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3474 LIBERTY RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4607
Mailing Address - Country:US
Mailing Address - Phone:503-588-8188
Mailing Address - Fax:503-588-0884
Practice Address - Street 1:3474 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4607
Practice Address - Country:US
Practice Address - Phone:503-588-8188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-13
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDP186082213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty