Provider Demographics
NPI:1609506849
Name:LIPPERT, TIMOTHY DILLON
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DILLON
Last Name:LIPPERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3450 VALLEY PLAZA PKWY
Mailing Address - Street 2:
Mailing Address - City:FT MITCHELL
Mailing Address - State:KY
Mailing Address - Zip Code:41017-8113
Mailing Address - Country:US
Mailing Address - Phone:859-341-3767
Mailing Address - Fax:859-341-3789
Practice Address - Street 1:3450 VALLEY PLAZA PKWY
Practice Address - Street 2:
Practice Address - City:FT MITCHELL
Practice Address - State:KY
Practice Address - Zip Code:41017-8113
Practice Address - Country:US
Practice Address - Phone:859-341-3767
Practice Address - Fax:859-341-3789
Is Sole Proprietor?:No
Enumeration Date:2022-06-11
Last Update Date:2022-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252558156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician