Healthcare Provider Details

I. General information

NPI: 1043704794
Provider Name (Legal Business Name): TIFFANY NICOLE GRAHAM O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY NICOLE HOOKS O.D.

II. Dates (important events)

Enumeration Date: 06/17/2018
Last Update Date: 12/11/2023
Certification Date: 12/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

566 TOLL GATE RD
WARWICK RI
02886-2799
US

IV. Provider business mailing address

2401 SUMMIT DR
BRIDGEWATER MA
02324-2183
US

V. Phone/Fax

Practice location:
  • Phone: 401-738-4800
  • Fax: 508-823-0425
Mailing address:
  • Phone: 774-506-2857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5309
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberODTG00662
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: