Basic Information
Provider Information | |||||||||
NPI: | 1447637350 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WEIDNER | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6341 FANNIN STREET SUITE JJL 310 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770305452 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7135007200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 6431 FANNIN ST STE MSB 4020 | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770301501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7135007200 | ||||||||
FaxNumber: | 7134860971 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/29/2015 | ||||||||
LastUpdateDate: | 07/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 52991 | AZ | N |   | Allopathic & Osteopathic Physicians | Surgery |   | 2086S0127X | T102 | TX | Y |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.