Basic Information
| Provider Information | |||||||||
| NPI: | 1255388013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT R IPPOLITO, MD, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9221 LBJ FWY | ||||||||
| Address2: | SUITE 208 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752433455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9726448577 | ||||||||
| FaxNumber: | 9726448577 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 MEDICAL PKWY | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752347858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729194747 | ||||||||
| FaxNumber: | 9729194749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 08/04/2008 | ||||||||
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| AuthorizedOfficialLastName: | IPPOLITO | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9728672731 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0122X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
ID Information
| ID | Type | State | Issuer | Description | 182655401 | 05 | TX | MEDICAID |