Basic Information
Provider Information | |||||||||
NPI: | 1417321969 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DODGE | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEFIORE | ||||||||
OtherFirstName: | TIFFANY | ||||||||
OtherMiddleName: | L. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 14690 SPRING HILL DR STE 305 | ||||||||
Address2: |   | ||||||||
City: | SPRING HILL | ||||||||
State: | FL | ||||||||
PostalCode: | 346098102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3522775348 | ||||||||
FaxNumber: | 3526062857 | ||||||||
Practice Location | |||||||||
Address1: | 5500 LITTLE RD | ||||||||
Address2: |   | ||||||||
City: | NEW PORT RICHEY | ||||||||
State: | FL | ||||||||
PostalCode: | 346551105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273721005 | ||||||||
FaxNumber: | 7278077081 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2015 | ||||||||
LastUpdateDate: | 01/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9109263 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | HUYKT | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | 016655400 | 05 | FL |   | MEDICAID |