Basic Information
| Provider Information | |||||||||
| NPI: | 1013900281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TIPPIN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2160 COLONIAL BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339071410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2399317342 | ||||||||
| FaxNumber: | 2399317385 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 N NEVADA AVE STE CC101 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809076819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7197765281 | ||||||||
| FaxNumber: | 7197762525 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 40881 | CO | N | Other Service Providers | Specialist | 2085R0001X | C154753 | CA | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | CDRH.0040881 | CO | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 04004909 | 05 | CO | MEDICAID |