Provider Demographics
NPI: | 1659660371 |
---|---|
Name: | TIFFANY, ELIZABETH MARIE (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ELIZABETH |
Middle Name: | MARIE |
Last Name: | TIFFANY |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | ELIZABETH |
Other - Middle Name: | MARIE |
Other - Last Name: | KRAFT |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | MD |
Mailing Address - Street 1: | 515 GARFIELD AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | MILFORD |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 45150-1143 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 513-227-7551 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 500 W FORT ST |
Practice Address - Street 2: | |
Practice Address - City: | BOISE |
Practice Address - State: | ID |
Practice Address - Zip Code: | 83702-4501 |
Practice Address - Country: | US |
Practice Address - Phone: | 208-353-8636 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2011-04-04 |
Last Update Date: | 2023-01-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | 35.122273 | 2084P0800X, 2084P0802X |
390200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0802X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Psychiatry |
No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 390200000X | Student, Health Care | Student in an Organized Health Care Education/Training Program |