Provider Demographics
NPI:1871094110
Name:LIPPINCOTT, JOHN KENNETH (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNETH
Last Name:LIPPINCOTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 SEWALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2625
Mailing Address - Country:US
Mailing Address - Phone:207-828-2020
Mailing Address - Fax:207-773-7034
Practice Address - Street 1:53 SEWALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2625
Practice Address - Country:US
Practice Address - Phone:207-828-2020
Practice Address - Fax:207-773-7034
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI76892207W00000X, 207WX0110X
MEMD28019207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1871094110Medicaid
WI1871094110Medicaid