Provider Demographics
NPI:1619948304
Name:SMART, TIFFANY TYLER (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:TYLER
Last Name:SMART
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 1:590 HARBOR ST
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1904
Mailing Address - Country:US
Mailing Address - Phone:805-772-1269
Mailing Address - Fax:805-772-2172
Practice Address - Street 1:590 HARBOR ST
Practice Address - Street 2:
Practice Address - City:MORRO BAY
Practice Address - State:CA
Practice Address - Zip Code:93442-1904
Practice Address - Country:US
Practice Address - Phone:805-772-1269
Practice Address - Fax:805-772-2172
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT12647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD01264701Medicaid
CA5964530001Medicare NSC
CAP00455478Medicare PIN
CASD01264701Medicaid