=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003877523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY N MCCALLA M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2006
-----------------------------------------------------
Last Update Date | 01/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12794 FOREST HILL BLVD STE 9-10
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-252-5398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12794 FOREST HILL BLVD STE 9-10
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-4710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-252-5398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | D0063078
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | M7412
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | ME103480
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------