Provider Demographics
NPI:1922412915
Name:GATES, TIFFANY (OD, FAAO, FSLS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GATES
Suffix:
Gender:F
Credentials:OD, FAAO, FSLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16860 SHERIDAN PKWY UNIT 106
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80023-8989
Mailing Address - Country:US
Mailing Address - Phone:720-598-2020
Mailing Address - Fax:720-893-9070
Practice Address - Street 1:16860 SHERIDAN PKWY UNIT 106
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80023-8989
Practice Address - Country:US
Practice Address - Phone:720-598-2020
Practice Address - Fax:720-893-9070
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3109152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO418903Z13Medicare PIN