Provider Demographics
NPI:1760820054
Name:KOON, TIFFANY (OD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:KOON
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 1:1127 MD RT 3 N # 104
Mailing Address - Street 2:
Mailing Address - City:GAMBRILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21054-1715
Mailing Address - Country:US
Mailing Address - Phone:410-988-2662
Mailing Address - Fax:410-988-4553
Practice Address - Street 1:1127 MD RT 3 N # 104
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054-1715
Practice Address - Country:US
Practice Address - Phone:410-988-2662
Practice Address - Fax:410-988-4553
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007964-1152W00000X
MDTA2446152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist