Healthcare Provider Details

I. General information

NPI: 1104833516
Provider Name (Legal Business Name): EDWARDO TELLEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16510 BLOOMFIELD AVE
CERRITOS CA
90703-9346
US

IV. Provider business mailing address

75 REMITTANCE DRIVE DEPT 6008
CHICAGO CA
60675-6008
US

V. Phone/Fax

Practice location:
  • Phone: 562-229-0902
  • Fax: 562-229-0952
Mailing address:
  • Phone: 562-282-1419
  • Fax: 562-920-4642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG63350
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63350
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: