Provider Demographics
NPI:1255742532
Name:RISNER, TIFFANY REBECCA (OD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:REBECCA
Last Name:RISNER
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 1:501 E KOLSTAD ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-2352
Mailing Address - Country:US
Mailing Address - Phone:903-731-4653
Mailing Address - Fax:903-723-5550
Practice Address - Street 1:208 W KNOX ST
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:TX
Practice Address - Zip Code:75119-4026
Practice Address - Country:US
Practice Address - Phone:469-456-0059
Practice Address - Fax:469-456-0020
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT003303152W00000X
TX11001152W00000X
CA15046TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX470989101Medicaid