Provider Demographics
NPI:1396019543
Name:TAYLOR, TIFFANY A (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:A
Other - Last Name:BOONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 841656
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-1656
Mailing Address - Country:US
Mailing Address - Phone:903-531-5000
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-525-1913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM96902080N0001X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-042OtherTRICARE
TXP01073155OtherRAIL ROAD
TX295428102Medicaid
TX8DD807OtherBCBS
TX8DD807OtherBCBS