Provider Demographics
NPI:1598283616
Name:O'NEAL, TIFFANY RENEE (IDC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:O'NEAL
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 ORO VISTA RD APT 194
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-4516
Mailing Address - Country:US
Mailing Address - Phone:770-371-3622
Mailing Address - Fax:
Practice Address - Street 1:1775 ORO VISTA RD APT 194
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4516
Practice Address - Country:US
Practice Address - Phone:770-371-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman