Provider Demographics
NPI:1235797713
Name:SMITH, TIFFANY (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-644-4300
Mailing Address - Fax:970-263-4323
Practice Address - Street 1:2478 PATTERSON RD STE 27
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81505-3606
Practice Address - Country:US
Practice Address - Phone:970-644-4300
Practice Address - Fax:970-263-4323
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL0007547207Q00000X
390200000X
CODR.0066555207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000173588Medicaid