Healthcare Provider Details

I. General information

NPI: 1871074500
Provider Name (Legal Business Name): TIFFANY L. GORMAN, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2018
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 E HACIENDA AVE STE B
CAMPBELL CA
95008-6625
US

IV. Provider business mailing address

221 E HACIENDA AVE STE B
CAMPBELL CA
95008-6625
US

V. Phone/Fax

Practice location:
  • Phone: 408-376-3350
  • Fax: 408-374-4130
Mailing address:
  • Phone: 408-376-3350
  • Fax: 408-374-4130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: SEAN MORRISSEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 408-376-3350