Provider Demographics
NPI:1629188404
Name:ANDERSON TERRELL, TIFFANY (DO)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:ANDERSON TERRELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5253 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4151
Mailing Address - Country:US
Mailing Address - Phone:909-464-2845
Mailing Address - Fax:909-464-2848
Practice Address - Street 1:5253 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4151
Practice Address - Country:US
Practice Address - Phone:909-464-2845
Practice Address - Fax:909-464-2848
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX85060Medicaid
CA00AXB5060N31OtherCAL OPTIMA
CAP00055172OtherRAILROAD MEDICARE
CA00AX85060Medicaid
CA00AXB5060N31OtherCAL OPTIMA
CA020A85060Medicare ID - Type Unspecified