Provider Demographics
NPI:1295939783
Name:HERNANDEZ, TIFFANY LACROSS (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LACROSS
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:M
Other - Last Name:LACROSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4033 TAMPA RD STE 101
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-855-2367
Practice Address - Street 1:3222 W AZEELE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-3280
Practice Address - Country:US
Practice Address - Phone:813-872-8491
Practice Address - Fax:813-872-7766
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107265208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002605000Medicaid