Provider Demographics
NPI:1407964737
Name:TIFFANY, MARK ALAN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:TIFFANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 E BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-3511
Mailing Address - Country:US
Mailing Address - Phone:520-399-6000
Mailing Address - Fax:520-399-6002
Practice Address - Street 1:4601 E BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-3511
Practice Address - Country:US
Practice Address - Phone:520-399-6000
Practice Address - Fax:520-399-6002
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-1545208VP0014X
AZ64010207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC138A5OtherBC
NC89138A5Medicaid
NC138A5OtherBC
NC89138A5Medicaid