Provider Demographics
NPI:1598927956
Name:TETELBOM, MIRIAM (MD)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:TETELBOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 BROAD STREET
Mailing Address - Street 2:SUITE # 3
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-2155
Mailing Address - Country:US
Mailing Address - Phone:732-503-9812
Mailing Address - Fax:
Practice Address - Street 1:316 BROAD STREET
Practice Address - Street 2:SUITE # 3
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-2155
Practice Address - Country:US
Practice Address - Phone:732-503-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2520782084P0804X
NJ25MA092841002084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry