Provider Demographics
NPI:1407964737
Name:TIFFANY, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2301 INDIAN WELLS RD STE A
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-4611
Mailing Address - Country:US
Mailing Address - Phone:575-434-0639
Mailing Address - Fax:575-551-5007
Practice Address - Street 1:2301 INDIAN WELLS RD STE A
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-4611
Practice Address - Country:US
Practice Address - Phone:575-434-0639
Practice Address - Fax:575-551-5007
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-1545208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138A5OtherBC
NC89138A5Medicaid
NC138A5OtherBC
NC89138A5Medicaid