Provider Demographics
NPI:1275293268
Name:TIEFENBRUN, MALKAH DOBA (DNP)
Entity Type:Individual
Prefix:DR
First Name:MALKAH
Middle Name:DOBA
Last Name:TIEFENBRUN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2117
Mailing Address - Country:US
Mailing Address - Phone:718-839-5592
Mailing Address - Fax:
Practice Address - Street 1:530 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2117
Practice Address - Country:US
Practice Address - Phone:718-839-5592
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-18
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01239100363L00000X, 363LF0000X
NYF348843-01363LF0000X
NJ26NR19215300207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0827924Medicaid