Basic Information
| Provider Information | |||||||||
| NPI: | 1235130402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIPPERLEY | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | OWENS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850164701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029551000 | ||||||||
| FaxNumber: | 6025084830 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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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 | 207W00000X | 16167 | AZ | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | 16167 | AZ | Y |
ID Information
| ID | Type | State | Issuer | Description | 285412 | 05 | AZ | MEDICAID |