Provider Demographics
NPI:1780619700
Name:TIFFANY, PETER N (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:N
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 WOODLAND RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1702
Mailing Address - Country:US
Mailing Address - Phone:781-979-0661
Mailing Address - Fax:
Practice Address - Street 1:3 WOODLAND RD
Practice Address - Street 2:SUITE 216
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1702
Practice Address - Country:US
Practice Address - Phone:781-979-0661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA54056208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3119386Medicaid
MA340005509OtherRR MEDICARE
MAJ04258OtherBCBS
MAGX1183Medicare PIN
MAJ04258Medicare UPIN