Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2082S0105X | Plastic Hand Surgeon | H9653 | TX |
NPI | 1124077573 |
---|---|
Provider Name | Dr. Robert Ippolito |
First Address | Dallas, TX 75243-3455 |
Second Address | Dallas, TX 75234-7852 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 04/08/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0063EQ | BC/BS (01) | TX |
096867902 | (05) | TX |
096867903 | (05) | TX |
E66728 | (02) | TX |
MDH9653 | WORKERS COMPENSATIONS (01) | TX |