Basic Information
| Provider Information | |||||||||
| NPI: | 1013917988 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPSCOMB | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19916 GEMSTONE DR | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773564937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814677840 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10850 LOUETTA RD | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770703533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813202338 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 08/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | G5303 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | G5303 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 135361703 | 05 | TX | MEDICAID |