Provider Demographics
NPI:1518385475
Name:WONG, TIFFANIE (DO)
Entity Type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:
Last Name:WONG
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 1:1450 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4505
Mailing Address - Country:US
Mailing Address - Phone:863-293-2147
Mailing Address - Fax:863-294-2767
Practice Address - Street 1:6020 PARK BLVD N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-3228
Practice Address - Country:US
Practice Address - Phone:855-353-7546
Practice Address - Fax:727-478-2909
Is Sole Proprietor?:No
Enumeration Date:2014-03-28
Last Update Date:2019-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS14348207Q00000X, 207N00000X
TXR4345207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program