Basic Information
| Provider Information | |||||||||
| NPI: | 1972764819 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONOUGH | ||||||||
| FirstName: | TIFFANI | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 92 CAMPUS DR STE B | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078854362 | ||||||||
| FaxNumber: | 2123426865 | ||||||||
| Practice Location | |||||||||
| Address1: | 92 CAMPUS DR STE B | ||||||||
| Address2: | |||||||||
| City: | SCARBOROUGH | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040747229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078854362 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2008 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084E0001X | MD25926 | ME | N | 2084N0402X | 255224 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology | 2084N0402X | MD25926 | ME | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology with Special Qualifications in Child Neurology |
ID Information
| ID | Type | State | Issuer | Description | MD25926 | 01 | ME | MEDICAL LICENSE | OTHER |