Basic Information
| Provider Information | |||||||||
| NPI: | 1154426187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIPSCOMB | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LIPSCOMB | ||||||||
| OtherFirstName: | JODY | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5012 S US HIGHWAY 75 STE 300 | ||||||||
| Address2: | ATTN BILLING | ||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750204589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034166200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5012 S US HIGHWAY 75 STE 110 | ||||||||
| Address2: | |||||||||
| City: | DENISON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750204596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9034166200 | ||||||||
| FaxNumber: | 9034166201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 04/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | M1206 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 200065760A | 05 | OK | MEDICAID | 174127401 | 05 | TX | MEDICAID |