Provider Demographics
NPI:1558658880
Name:RICHASON, TIFFANY PAMELA (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:PAMELA
Last Name:RICHASON
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 1:1350 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3224
Mailing Address - Country:US
Mailing Address - Phone:407-975-0406
Mailing Address - Fax:407-975-0407
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:407-975-0406
Practice Address - Fax:407-975-0407
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO50228207V00000X
FLME149676207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO308265YTUOMedicare PIN