Healthcare Provider Details

I. General information

NPI: 1669843751
Provider Name (Legal Business Name): GEORGE S TELLAM DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 3RD ST S
JACKSONVILLE BEACH FL
32250-6028
US

IV. Provider business mailing address

981 KINGSLEY AVE
ORANGE PARK FL
32073-4742
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-9595
  • Fax: 904-264-5211
Mailing address:
  • Phone: 904-269-9595
  • Fax: 904-264-5211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO 1636
License Number StateFL

VIII. Authorized Official

Name: SHELLEY SAWDAY THOMAS
Title or Position: OWNER/PODIATRIST
Credential: DPM
Phone: 904-269-9595