Healthcare Provider Details

I. General information

NPI: 1124588868
Provider Name (Legal Business Name): TIFFANY LAITANO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 14TH ST SW
LARGO FL
33770-3199
US

IV. Provider business mailing address

612 DRUID RD E
CLEARWATER FL
33756-3912
US

V. Phone/Fax

Practice location:
  • Phone: 727-588-5200
  • Fax:
Mailing address:
  • Phone: 727-443-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME156870
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: