1003877523 NPI number — TIFFANY N MCCALLA M.D.

Table of content: TIFFANY N MCCALLA M.D. (NPI 1003877523)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003877523 NPI number — TIFFANY N MCCALLA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCALLA
Provider First Name:
TIFFANY
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.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:
1003877523
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12794 FOREST HILL BLVD STE 9-10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414-4710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-252-5398
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12794 FOREST HILL BLVD STE 9-10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLINGTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33414-4710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-252-5398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2006

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: 174400000X , with the licence number:  D0063078 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: M7412 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X , with the licence number: ME103480 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 8U4003 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 189741501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 408208700 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8AX740 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 001169400 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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