Provider Demographics
NPI:1518340058
Name:SHAM, TIFFANY (DO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:925-915-1362
Mailing Address - Fax:
Practice Address - Street 1:3231 EUCLID AVE
Practice Address - Street 2:5TH FLOOR
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3471
Practice Address - Country:US
Practice Address - Phone:708-783-2000
Practice Address - Fax:708-783-3656
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125070732207Q00000X
CA18473207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine