Healthcare Provider Details

I. General information

NPI: 1205182953
Provider Name (Legal Business Name): TIFFANY JEAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2012
Last Update Date: 09/21/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

101 THE CITY DR S
ORANGE CA
92868-3201
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-7890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA126760
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: