Provider Demographics
NPI:1104833516
Name:TELLEZ, EDWARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARDO
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMITTANCE DRIVE DEPT 6008
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:CA
Mailing Address - Zip Code:60675-6008
Mailing Address - Country:US
Mailing Address - Phone:562-282-1419
Mailing Address - Fax:562-920-4642
Practice Address - Street 1:16510 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9346
Practice Address - Country:US
Practice Address - Phone:562-229-0902
Practice Address - Fax:562-229-0952
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG63350208000000X
CA63350208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G63350OtherBLUE SHIELD
CA00G63350CMedicaid
CA370020277OtherMEDICARE RAILROAD
CA370020277OtherRAILROAD MEDICARE
CA00G633500Medicaid
CAWG63350CMedicare PIN
CA00G63350OtherBLUE SHIELD