1912136755 NPI number — DR. TIFFANY PROCACCINI O.D.

Table of content: DR. TIFFANY PROCACCINI O.D. (NPI 1912136755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912136755 NPI number — DR. TIFFANY PROCACCINI O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PROCACCINI
Provider First Name:
TIFFANY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1912136755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLARD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44890-0270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-933-2741
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
320 W WALTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLARD
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44890-9133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-933-2741
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2009

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: 152W00000X , with the licence number:  5906 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1043330871 . This is a "GROUP NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 9292043 . This is a "GROUP PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 2988521 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: CG0387 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: 1912136755 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: H060602 . This is a "INDIVIDUAL PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".
  • Identifier: P01269559 . This is a "RAILROAD MEDCIARE PTAN" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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