Provider Demographics
NPI:1154779692
Name:KUBIS, TIFFANY MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:MARIE
Last Name:KUBIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 BOARDMAN CANFIELD RD
Mailing Address - Street 2:APT 64B
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-8056
Mailing Address - Country:US
Mailing Address - Phone:740-584-1588
Mailing Address - Fax:
Practice Address - Street 1:45 MANOR HILL DR
Practice Address - Street 2:SUITE 100
Practice Address - City:CANFIELD
Practice Address - State:OH
Practice Address - Zip Code:44406-1527
Practice Address - Country:US
Practice Address - Phone:330-702-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist