Provider Demographics
NPI:1124254123
Name:RUSSELL, TIFFANY E (MD)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:E
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:E
Other - Last Name:STURGEON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3630
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86003-3630
Mailing Address - Country:US
Mailing Address - Phone:928-522-9400
Mailing Address - Fax:970-240-3095
Practice Address - Street 1:1510 N STOCKTON HILL RD
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-5173
Practice Address - Country:US
Practice Address - Phone:928-753-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-03
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR0052648207R00000X, 208000000X
AZ332359207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics