Healthcare Provider Details

I. General information

NPI: 1730365834
Provider Name (Legal Business Name): DR. GEORGE S TELLAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2008
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

981 KINGSLEY AVE
ORANGE PARK FL
32073-4742
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 Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO1636
License Number StateFL

VIII. Authorized Official

Name: DR. GEORGE TELLAM
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 904-269-6565