Provider Demographics
NPI:1265498836
Name:KIPPER, SAMUEL L (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:L
Last Name:KIPPER
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:PO BOX 6279
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-6279
Mailing Address - Country:US
Mailing Address - Phone:866-727-1072
Mailing Address - Fax:800-508-4751
Practice Address - Street 1:1100 N TUSTIN AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3509
Practice Address - Country:US
Practice Address - Phone:714-835-6055
Practice Address - Fax:714-285-9084
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2014-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA345002085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A345000Medicaid
360004475OtherRAILROAD MEDICARE
CA00A345000Medicaid
CAEK898YMedicare PIN
360004475OtherRAILROAD MEDICARE
WA34500CMedicare PIN
WA34500BMedicare PIN