Provider Demographics
NPI:1932142809
Name:JOHNSON, TIFFANIE (MD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANIE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-944-8906
Mailing Address - Fax:
Practice Address - Street 1:575 RILEY HOSPITAL DR. MSA 2
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-8906
Practice Address - Fax:317-274-4022
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010545822085P0229X, 2085R0202X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64070253Medicaid
VT1011498Medicaid
IN200455010Medicaid
145590H6Medicare PIN
IN959090W9Medicare PIN
INH96301Medicare UPIN
IN200455010Medicaid