Provider Demographics
NPI:1720491889
Name:BONNECAZE, TIFFANY EARLE (MD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:EARLE
Last Name:BONNECAZE
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 1:205 PAGE ROAD N
Mailing Address - Street 2:
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-6810
Mailing Address - Country:US
Mailing Address - Phone:901-295-9211
Mailing Address - Fax:
Practice Address - Street 1:205 PAGE RD
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8798
Practice Address - Country:US
Practice Address - Phone:901-295-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-06
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3902200000X390200000X
NC2021-00612207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program