Provider Demographics
NPI:1558985671
Name:LUNDBERG, TIFFANY (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LUNDBERG
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 1:2010 W LINCOLN AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2413
Mailing Address - Country:US
Mailing Address - Phone:509-965-5200
Mailing Address - Fax:509-452-7563
Practice Address - Street 1:2010 W LINCOLN AVE STE 1
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2413
Practice Address - Country:US
Practice Address - Phone:509-965-5200
Practice Address - Fax:509-452-7563
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61058089152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist