Basic Information
| Provider Information | |||||||||
| NPI: | 1548228570 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIPOME | ||||||||
| FirstName: | DOMINIC | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6255 SHERIDAN DR | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142214836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168578666 | ||||||||
| FaxNumber: | 7168578944 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 HIGH ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031149 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166301000 | ||||||||
| FaxNumber: | 7168594035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 208074-1 | NY | X | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 208074-1 | NY | X | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 208074-5W | 01 | NY | WORKERS COMPENSATION | OTHER | 000525802002 | 01 | NY | HEALTH NOW | OTHER | 01945151 | 05 | NY | MEDICAID | 0410903 | 01 | NY | IHA | OTHER | 00020518602 | 01 | NY | UNIVERA | OTHER |