Provider Demographics
NPI:1952607251
Name:REAVIS, TIFFANY BROOK (DO)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:BROOK
Last Name:REAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 55TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11220-2508
Mailing Address - Country:US
Mailing Address - Phone:909-636-6497
Mailing Address - Fax:
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:909-636-6497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259626208600000X, 2082S0105X, 2086S0127X
AZ005932208600000X, 2086S0127X
WAOP 60329393208200000X, 208600000X
FLOS 12793208600000X, 208200000X, 2086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery