Provider Demographics
NPI:1720170590
Name:LIPPINCOTT, TYLER B (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:B
Last Name:LIPPINCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:233 NE 102ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-4106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:233 NE 102ND AVE
Practice Address - Street 2:
Practice Address - City:PORTAND
Practice Address - State:OR
Practice Address - Zip Code:97220
Practice Address - Country:US
Practice Address - Phone:503-253-1105
Practice Address - Fax:503-535-8398
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD167182085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR106197Medicare ID - Type Unspecified
F86834Medicare UPIN