Provider Demographics
NPI:1255466728
Name:JOHNSON, TIFFANY J (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:J
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:TIFFANY
Other - Middle Name:J
Other - Last Name:STUCKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:9540 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1313
Practice Address - Country:US
Practice Address - Phone:314-962-3830
Practice Address - Fax:314-962-3909
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005025566152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO936297473Medicare ID - Type Unspecified
MOV06994Medicare UPIN
MOMA5227017Medicare UPIN