Provider Demographics
NPI:1932123106
Name:GORMAN, TIFFANY (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:GORMAN
Other - Last Name:MORRISSEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:221 E HACIENDA AVE
Mailing Address - Street 2:STE B
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6616
Mailing Address - Country:US
Mailing Address - Phone:408-376-3350
Mailing Address - Fax:408-374-4130
Practice Address - Street 1:221 E HACIENDA AVE
Practice Address - Street 2:STE B
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008
Practice Address - Country:US
Practice Address - Phone:408-376-3350
Practice Address - Fax:408-374-4130
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA061360207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A613600Medicare PIN