Provider Demographics
NPI:1982695219
Name:CLEGG, TIFFIN (MD)
Entity Type:Individual
Prefix:
First Name:TIFFIN
Middle Name:
Last Name:CLEGG
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 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:360-782-3600
Mailing Address - Fax:
Practice Address - Street 1:9398 RIDGETOP BLVD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8505
Practice Address - Country:US
Practice Address - Phone:360-782-3200
Practice Address - Fax:360-782-3240
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1041265Medicaid