Healthcare Provider Details

I. General information

NPI: 1750794954
Provider Name (Legal Business Name): TIFFANY J TAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2496 BAUER ROAD
SAN DIEGO CA
92145-1044
US

IV. Provider business mailing address

2496 BAUER ROAD
SAN DIEGO CA
92145-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-307-4645
  • Fax: 858-307-9849
Mailing address:
  • Phone: 858-307-9907
  • Fax: 858-307-9849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: