Healthcare Provider Details

I. General information

NPI: 1982695219
Provider Name (Legal Business Name): TIFFIN CLEGG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 02/11/2022
Certification Date: 02/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9398 RIDGETOP BLVD NW
SILVERDALE WA
98383-8505
US

IV. Provider business mailing address

9621 RIDGETOP BLVD NW
SILVERDALE WA
98383-8502
US

V. Phone/Fax

Practice location:
  • Phone: 360-782-3200
  • Fax: 360-782-3240
Mailing address:
  • Phone: 360-782-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00041312
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: