Basic Information
| Provider Information | |||||||||
| NPI: | 1972824712 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANFILL | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | STANFILL THOMAS | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708125735 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 DALLAS HWY | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301801264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708123850 | ||||||||
| FaxNumber: | 7704563826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2010 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 071171 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 003138180B | 05 | GA | MEDICAID |