Healthcare Provider Details

I. General information

NPI: 1790362465
Provider Name (Legal Business Name): BORIS TIZENBERG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2021
Last Update Date: 07/05/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 CARROLL CREEK WAY STE 320
FREDERICK MD
21701-7106
US

IV. Provider business mailing address

50 CARROLL CREEK WAY STE 320
FREDERICK MD
21701-7106
US

V. Phone/Fax

Practice location:
  • Phone: 443-708-5856
  • Fax:
Mailing address:
  • Phone: 443-708-5856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD0097642
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: