Healthcare Provider Details

I. General information

NPI: 1003172347
Provider Name (Legal Business Name): TIFFANY PRUGPICHAILERS PEDIGO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY PRUGPICHAILERS M.D.

II. Dates (important events)

Enumeration Date: 04/11/2012
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ B711 RRUMC
LOS ANGELES CA
90095-7419
US

IV. Provider business mailing address

757 WESTWOOD PLZ B711 RRUMC
LOS ANGELES CA
90095-7419
US

V. Phone/Fax

Practice location:
  • Phone: 310-267-9129
  • Fax:
Mailing address:
  • Phone: 310-267-9129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA130852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: