Healthcare Provider Details

I. General information

NPI: 1396769436
Provider Name (Legal Business Name): TIFFANY MARIE WILLARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E BOULDER ST SUITE 600
COLORADO SPRINGS CO
80909-5533
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-364-6487
  • Fax: 719-364-6488
Mailing address:
  • Phone: 970-624-2412
  • Fax: 719-364-6488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0046934
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberDR.0046934
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: