Provider Demographics
NPI:1417120734
Name:MERRICK MIKHAEL, TIFFANY PAMELA (DO)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:PAMELA
Last Name:MERRICK MIKHAEL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:PAMELA
Other - Last Name:MERRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:9985 SIERRA AVE
Mailing Address - Street 2:MOB 2
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-6720
Mailing Address - Country:US
Mailing Address - Phone:909-427-5000
Mailing Address - Fax:
Practice Address - Street 1:9985 SIERRA AVE
Practice Address - Street 2:MOB 2
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-6720
Practice Address - Country:US
Practice Address - Phone:909-427-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-08
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11021208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics