Provider Demographics
NPI:1649400870
Name:LEWIS, TIFFANY CHRISTINE (DO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CHRISTINE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8020 CONSTITUTION PL NE STE 202
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7640
Mailing Address - Country:US
Mailing Address - Phone:505-998-3096
Mailing Address - Fax:505-998-3100
Practice Address - Street 1:8020 CONSTITUTION PL NE STE 202
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-998-3096
Practice Address - Fax:505-998-3100
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2171-182085R0202X
MO20150273452085R0202X, 2085R0202X
KS05-345512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86639323Medicaid
AZ928556Medicaid