Provider Demographics
NPI:1649689464
Name:JEN, TIFFANY (MD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:JEN
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:UB 2ND FLOOR
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-834-7970
Mailing Address - Fax:760-834-7971
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:UB 2ND FLOOR
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-834-7970
Practice Address - Fax:760-834-7971
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2016-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA133773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program