Healthcare Provider Details

I. General information

NPI: 1952607251
Provider Name (Legal Business Name): TIFFANY BROOK REAVIS D.O., F.A.C.O.S
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 CENTRAL PARK W APT 20H
NEW YORK NY
10023-7204
US

IV. Provider business mailing address

25 CENTRAL PARK W APT 20H
NEW YORK NY
10023-7204
US

V. Phone/Fax

Practice location:
  • Phone: 909-636-6497
  • Fax:
Mailing address:
  • Phone: 909-636-6497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberOS 12793
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number259626
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number259626
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number005932
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOP 60329393
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number259626
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberOS 12793
License Number StateFL
# 8
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberOS 12793
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number005932
License Number StateAZ
# 10
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberOP 60329393
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: