Provider Demographics
NPI:1356581979
Name:COLARUSSO, TIFFANY (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:COLARUSSO
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 1:9111 OLD MILL ST
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-6415
Mailing Address - Country:US
Mailing Address - Phone:404-861-6315
Mailing Address - Fax:
Practice Address - Street 1:1015 DONALD LEE HOLLOWELL PKWY NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-6653
Practice Address - Country:US
Practice Address - Phone:404-523-6571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-22
Last Update Date:2009-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053146208000000X
TXL9447208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics