Healthcare Provider Details

I. General information

NPI: 1801858485
Provider Name (Legal Business Name): TIFFANY L JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

1919 E THOMAS RD BLDG. C MANAGED CARE
PHOENIX AZ
85016-7710
US

V. Phone/Fax

Practice location:
  • Phone: 602-546-1000
  • Fax:
Mailing address:
  • Phone: 602-546-0486
  • Fax: 602-546-1631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number34205
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: