Provider Demographics
NPI:1003877523
Name:MCCALLA, TIFFANY N (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:N
Last Name:MCCALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12794 FOREST HILL BLVD STE 9-10
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4710
Mailing Address - Country:US
Mailing Address - Phone:561-252-5398
Mailing Address - Fax:
Practice Address - Street 1:12794 FOREST HILL BLVD STE 9-10
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4710
Practice Address - Country:US
Practice Address - Phone:561-252-5398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-01
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0063078174400000X
TXM7412207P00000X
FLME103480207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8U4003OtherBCBS
TX189741501Medicaid
MD408208700Medicaid
TX8AX740OtherBCBS
TXP00444460Medicare PIN
MDM451Medicare PIN
TXI38382Medicare UPIN