Basic Information
Provider Information
NPI: 1003144858
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LIPOVACA
FirstName: SANDRA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5701 W CHARLESTON BLVD
Address2: SUITE 100
City: LAS VEGAS
State: NV
PostalCode: 891461217
CountryCode: US
TelephoneNumber: 7028779514
FaxNumber: 7023123510
Practice Location
Address1: 5701 W CHARLESTON BLVD
Address2: SUITE 100
City: LAS VEGAS
State: NV
PostalCode: 891461217
CountryCode: US
TelephoneNumber: 7028779514
FaxNumber: 7023123510
Other Information
ProviderEnumerationDate: 12/04/2009
LastUpdateDate: 12/04/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
208000000X13353NVY Allopathic & Osteopathic PhysiciansPediatrics 

ID Information
IDTypeStateIssuerDescription
1335301NVLICENSEOTHER


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