Healthcare Provider Details

I. General information

NPI: 1073773313
Provider Name (Legal Business Name): TIFFANY CHANEL WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 11/10/2023
Certification Date: 11/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 FOREST GLEN RD SUITE 500
SILVER SPRING MD
20910-1459
US

IV. Provider business mailing address

1400 FOREST GLEN RD SUITE 500
SILVER SPRING MD
20910-1459
US

V. Phone/Fax

Practice location:
  • Phone: 301-681-6772
  • Fax: 301-681-2773
Mailing address:
  • Phone: 301-681-6772
  • Fax: 301-681-2773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberD76784
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberDR.0070670
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD040762
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: