Provider Demographics
NPI:1952320459
Name:GILLIAM, TIFANI DAVIS (MD)
Entity Type:Individual
Prefix:MRS
First Name:TIFANI
Middle Name:DAVIS
Last Name:GILLIAM
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 1:900 23RD ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-2342
Mailing Address - Country:US
Mailing Address - Phone:202-715-5190
Mailing Address - Fax:
Practice Address - Street 1:2121 MEDICAL PARK DR
Practice Address - Street 2:STE 3
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20902-4054
Practice Address - Country:US
Practice Address - Phone:301-681-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0358102085R0202X
MDD666542085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD410243601Medicaid
DC003721D05Medicare PIN
DC194821YXFMedicare PIN
MD410243601Medicaid