Provider Demographics
NPI:1265437727
Name:TIEFENBRUN, JONATHAN (MD)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:TIEFENBRUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9610 GRANITE RIDGE DR
Mailing Address - Street 2:STE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2684
Mailing Address - Country:US
Mailing Address - Phone:858-810-8000
Mailing Address - Fax:858-268-1911
Practice Address - Street 1:8851 CENTER DR
Practice Address - Street 2:STE 505
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3017
Practice Address - Country:US
Practice Address - Phone:619-461-3880
Practice Address - Fax:619-461-3895
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2015-09-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAB188612085U0001X
CAG85951208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG85951AOtherSO CA MEDICARE PTAN
CAWG85951AOtherSO CA MEDICARE PTAN
CAB18861Medicare UPIN