Healthcare Provider Details

I. General information

NPI: 1619331923
Provider Name (Legal Business Name): RENE TELLEZ JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W STE 1600
ORANGE CA
92868-5903
US

IV. Provider business mailing address

333 CITY BLVD W STE 1600
ORANGE CA
92868-5903
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5532
  • Fax: 714-456-7207
Mailing address:
  • Phone: 714-456-5532
  • Fax: 714-456-7207

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA151199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: