1104833516 NPI number — DR. EDWARDO TELLEZ M.D.

Table of content: DR. EDWARDO TELLEZ M.D. (NPI 1104833516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104833516 NPI number — DR. EDWARDO TELLEZ M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TELLEZ
Provider First Name:
EDWARDO
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104833516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/25/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 REMITTANCE DRIVE DEPT 6008
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
60675-6008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-282-1419
Provider Business Mailing Address Fax Number:
562-920-4642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16510 BLOOMFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CERRITOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90703-9346
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-229-0902
Provider Business Practice Location Address Fax Number:
562-229-0952
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  G63350 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 63350 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G63350 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G63350C , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 370020277 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 370020277 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00G633500 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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