Provider Demographics
NPI:1003376203
Name:ROBAK, TIFFANY A (DO)
Entity Type:Individual
Prefix:DR
First Name:TIFFANY
Middle Name:A
Last Name:ROBAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3201 ZAFARANO DR STE C PMB 249
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-405-8423
Mailing Address - Fax:505-485-0641
Practice Address - Street 1:505 CAMINO DE LOS MARQUEZ
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-1837
Practice Address - Country:US
Practice Address - Phone:505-405-8423
Practice Address - Fax:505-485-0641
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-22
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.075065207QS0010X
FL390200000X
NMDO2022-0143207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program