Provider Demographics
NPI:1396769436
Name:WILLARD, TIFFANY MARIE (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:WILLARD
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 1:2695 ROCKY MOUNTAIN AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-9071
Mailing Address - Country:US
Mailing Address - Phone:970-624-2412
Mailing Address - Fax:719-364-6488
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 600
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-364-6487
Practice Address - Fax:719-364-6488
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0046934208600000X, 2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20634064Medicaid
CO20634064Medicaid
COCOA106143Medicare PIN
IL036112408Medicaid
COCOA109682Medicare PIN