Healthcare Provider Details

I. General information

NPI: 1609864628
Provider Name (Legal Business Name): TIFFANY M WEDLAKE M.D., MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 11/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 KIRK AVE
BALTIMORE MD
21218-5507
US

IV. Provider business mailing address

2400 KIRK AVE
BALTIMORE MD
21218-5507
US

V. Phone/Fax

Practice location:
  • Phone: 410-383-8300
  • Fax:
Mailing address:
  • Phone: 410-383-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number2007-01439
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number056784
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberD0076061
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: