1417120734 NPI number — DR. TIFFANY PAMELA MERRICK MIKHAEL DO

Table of content: DR. TIFFANY PAMELA MERRICK MIKHAEL DO (NPI 1417120734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417120734 NPI number — DR. TIFFANY PAMELA MERRICK MIKHAEL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MERRICK MIKHAEL
Provider First Name:
TIFFANY
Provider Middle Name:
PAMELA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MERRICK
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
PAMELA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417120734
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9985 SIERRA AVE
Provider Second Line Business Mailing Address:
MOB 2
Provider Business Mailing Address City Name:
FONTANA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92335-6720
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-427-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9985 SIERRA AVE
Provider Second Line Business Practice Location Address:
MOB 2
Provider Business Practice Location Address City Name:
FONTANA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92335-6720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-427-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  20A11021 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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