Provider Demographics
NPI:1316267404
Name:PROVIDENCE, TIFFANY OVERSTREET (DO)
Entity type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:OVERSTREET
Last Name:PROVIDENCE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:SOPHIA
Other - Last Name:OVERSTREET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4055 VALLEY VIEW LN STE 400
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75244-5071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4055 VALLEY VIEW LN STE 400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75244-5071
Practice Address - Country:US
Practice Address - Phone:469-466-7420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010215342085R0202X
GA0752022085R0202X
GA752022085R0202X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice