Provider Demographics
NPI:1881190783
Name:MARK, TIFFANY ELIZABETH
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ELIZABETH
Last Name:MARK
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 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-4380
Mailing Address - Fax:
Practice Address - Street 1:6201 GREENLEIGH AVE
Practice Address - Street 2:
Practice Address - City:MIDDLE RIVER
Practice Address - State:MD
Practice Address - Zip Code:21220-2004
Practice Address - Country:US
Practice Address - Phone:410-933-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD94103208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty