MEDICARE: DR. JONATHAN TIEFENBRUN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085U0001X	Diagnostic Ultrasound Physician	B18861	CA
2	208600000X	Surgery Physician	G85951	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	WG85951A	OTHER	CA	SO CA MEDICARE PTAN

General Provider Information

NPI Number	:	1265437727
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN TIEFENBRUN M.D.

Provider Business Mailing Address
First Line	:	9610 GRANITE RIDGE DR
Second Line	:	STE B
City	:	SAN DIEGO
State	:	CA
Zip	:	92123-2684
Country	:	US
Telephone Number	:	858-810-8000
Fax Number	:	858-268-1911

Provider Business Practice Location Address
First Line	:	8851 CENTER DR
Second Line	:	STE 505
City	:	LA MESA
State	:	CA
Zip	:	91942-3017
Country	:	US
Telephone Number	:	619-461-3880
Fax Number	:	619-461-3895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	09/18/2015

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Directions to “ DR. JONATHAN TIEFENBRUN M.D.” Practice Location

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