Provider Demographics
NPI:1720575913
Name:LA, TIFFANY (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LA
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 1:1720 EL CAMINO REAL
Mailing Address - Street 2:STE 235
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3213
Mailing Address - Country:US
Mailing Address - Phone:650-259-0300
Mailing Address - Fax:650-259-0505
Practice Address - Street 1:5275 CLAREMONT AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-1032
Practice Address - Country:US
Practice Address - Phone:510-528-3026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34249TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist