Provider Demographics
NPI:1477594844
Name:LE, TIFFANY (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:LE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9712 STURGEON DR NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-8452
Mailing Address - Country:US
Mailing Address - Phone:919-606-2802
Mailing Address - Fax:
Practice Address - Street 1:4540 MAIN ST
Practice Address - Street 2:
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28459-3079
Practice Address - Country:US
Practice Address - Phone:910-754-3358
Practice Address - Fax:910-154-9326
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1913152W00000X, 152WC0802X, 152WS0006X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WS0006XEye and Vision Services ProvidersOptometristSports Vision
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC093PEOtherBCBS NUMBER
NC89093PEMedicaid
NC2473131Medicare ID - Type UnspecifiedMEDICARE NUMBER
NC89093PEMedicaid