Provider Demographics
NPI:1679281174
Name:ALTIDOR, TIFFANY CRYSTAL
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CRYSTAL
Last Name:ALTIDOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 GORMLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-2416
Mailing Address - Country:US
Mailing Address - Phone:516-884-5998
Mailing Address - Fax:
Practice Address - Street 1:59 GORMLEY AVE
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:NY
Practice Address - Zip Code:11575-2416
Practice Address - Country:US
Practice Address - Phone:516-884-5998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1194063016OtherEIP
NY256260OtherEIP