Provider Demographics
NPI:1912136755
Name:PROCACCINI, TIFFANY (OD)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:
Last Name:PROCACCINI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 270
Mailing Address - Street 2:
Mailing Address - City:WILLARD
Mailing Address - State:OH
Mailing Address - Zip Code:44890-0270
Mailing Address - Country:US
Mailing Address - Phone:419-933-2741
Mailing Address - Fax:
Practice Address - Street 1:320 W WALTON ST
Practice Address - Street 2:
Practice Address - City:WILLARD
Practice Address - State:OH
Practice Address - Zip Code:44890-9133
Practice Address - Country:US
Practice Address - Phone:419-933-2741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-14
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5906152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1043330871OtherGROUP NPI
OH9292043OtherGROUP PTAN
OH2988521Medicaid
OHCG0387OtherRAILROAD MEDICARE GROUP PTAN
OH1912136755OtherINDIVIDUAL NPI
OHH060602OtherINDIVIDUAL PTAN
OHP01269559OtherRAILROAD MEDCIARE PTAN
OHH060602OtherINDIVIDUAL PTAN