Healthcare Provider Details

I. General information

NPI: 1700877057
Provider Name (Legal Business Name): TIFFANY D WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 12/26/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 CREEK RD BLDG A STE 140
IRVINE CA
92604-4724
US

IV. Provider business mailing address

PO BOX 1744
SUISUN CITY CA
94585-4744
US

V. Phone/Fax

Practice location:
  • Phone: 949-559-4480
  • Fax: 949-262-7072
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA70066
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: