Basic Information
| Provider Information | |||||||||
| NPI: | 1164408811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLIPSHAM | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 MIDPOINT DR STE B | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805254408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704881666 | ||||||||
| FaxNumber: | 9704729381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 11/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 45131 | CO | Y | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 45131 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00472222 | 01 | CO | RAILROAD MEDICARE | OTHER | 35959223 | 05 | CO | MEDICAID |