Provider Demographics
NPI:1336118025
Name:TIEFENBRUNN, LARRY J (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
Last Name:TIEFENBRUNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 CRANBURY RD
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-3612
Mailing Address - Country:US
Mailing Address - Phone:732-390-8400
Mailing Address - Fax:732-390-8970
Practice Address - Street 1:503 CRANBURY RD
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3612
Practice Address - Country:US
Practice Address - Phone:732-390-8400
Practice Address - Fax:732-390-8970
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2017-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0477702080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0070672OtherQUALCARE/GHI ID NY
NJP2676479OtherOXFORD
NJ202433OtherUNITED ID
NJMA047770OtherHIP/PHCS
NJF06243OtherHEALTHNET ID
NJ222694202OtherTIN