Healthcare Provider Details

I. General information

NPI: 1003376203
Provider Name (Legal Business Name): TIFFANY A ROBAK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2019
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 CAMINO DE LOS MARQUEZ
SANTA FE NM
87505-1837
US

IV. Provider business mailing address

3201 ZAFARANO DR STE C PMB 249
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-405-8423
  • Fax: 505-485-0641
Mailing address:
  • Phone: 505-405-8423
  • Fax: 505-485-0641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO2022-0143
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number125.075065
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: