Basic Information
| Provider Information | |||||||||
| NPI: | 1770789604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LIPTON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | HARRIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 222 W 39TH AVE | ||||||||
| Address2: | |||||||||
| City: | SAN MATEO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 944034364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505732671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2007 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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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 | 207P00000X | A79152 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A791520 | 05 | CA | MEDICAID |