Healthcare Provider Details

I. General information

NPI: 1972645307
Provider Name (Legal Business Name): LOUISA MAE TIFT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 E TREMONT AVE
BRONX NY
10465-2038
US

IV. Provider business mailing address

3620 E TREMONT AVE 2ND FLOOR
BRONX NY
10465-2038
US

V. Phone/Fax

Practice location:
  • Phone: 718-792-4700
  • Fax: 718-792-1255
Mailing address:
  • Phone: 718-792-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number242339
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: