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General NPI Number Information
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NPI Number | 1124254123
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Entity Type | Individual
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Provider Name | TIFFANY E RUSSELL MD
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Gender | Female
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Dates
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Enumeration Date | 06/03/2009
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Last Update Date | 12/14/2023
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Provider Practice Location Address
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Address Line | 1510 N STOCKTON HILL RD
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City | KINGMAN
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State | AZ
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Zip | 86401-5173
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Country | US
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Telephone | 928-753-1177
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3630
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City | FLAGSTAFF
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State | AZ
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Zip | 86003-3630
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Country | US
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Telephone | 928-522-9400
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Fax | 970-240-3095
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | DR0052648
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | DR0052648
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License Number State | CO
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 332359
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License Number State | AZ
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