Healthcare Provider Details

I. General information

NPI: 1144398413
Provider Name (Legal Business Name): TIFFANY MADSEN OHTA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2006
Last Update Date: 01/27/2025
Certification Date: 01/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6488 WEDDINGTON MONROE RD
WESLEY CHAPEL NC
28104-7948
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-8460
  • Fax: 704-384-1018
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2016-00856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: