Provider Demographics
NPI:1447393046
Name:JUSTICE, TIFFANY DEBORAH (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DEBORAH
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4123 DUTCHMANS LANE
Mailing Address - Street 2:SUITE 414
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4733
Mailing Address - Country:US
Mailing Address - Phone:502-897-2144
Mailing Address - Fax:502-897-1773
Practice Address - Street 1:4123 DUTCHMANS LANE
Practice Address - Street 2:SUITE 414
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4733
Practice Address - Country:US
Practice Address - Phone:502-897-2144
Practice Address - Fax:502-897-1773
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43562207VE0102X, 207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200983310Medicaid
KY000000665986OtherANTHEM PSC LOCATION
KY000000665914OtherANTHEM FONDATION LOCATION
KY50029221OtherPASSPORT SPECIALIST & SPECIALIST PAD# FOR FOUNDATION
KY50029222OtherPCP FOUNDATION & PCP PAD#
KY50029224OtherPASSPORT SPECIALIST & PASSPORT ADVANTAGE (PAD)#- PSC LOCATION
KY7100126700Medicaid
IN200983310Medicaid
KYK048201Medicare PIN
KY0722563Medicare PIN