Provider Demographics
NPI:1265016141
Name:MADDOX, TIFFANY (SPECIALIST)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MADDOX
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:MRS
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SPECIALIST
Mailing Address - Street 1:9914 HAGEL CIR
Mailing Address - Street 2:
Mailing Address - City:LORTON
Mailing Address - State:VA
Mailing Address - Zip Code:22079-4306
Mailing Address - Country:US
Mailing Address - Phone:832-537-4426
Mailing Address - Fax:276-530-4153
Practice Address - Street 1:14497 POTOMAC MILLS RD # 1013
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-6807
Practice Address - Country:US
Practice Address - Phone:571-570-6361
Practice Address - Fax:276-530-4153
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-07
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier