Healthcare Provider Details

I. General information

NPI: 1972458578
Provider Name (Legal Business Name): MARCO ANTONIO TELLO JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4302 ALTON RD STE 220
MIAMI BEACH FL
33140-2818
US

IV. Provider business mailing address

4302 ALTON RD STE 220
MIAMI BEACH FL
33140-2818
US

V. Phone/Fax

Practice location:
  • Phone: 305-674-2090
  • Fax:
Mailing address:
  • Phone: 305-674-2090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: