Provider Demographics
NPI:1154319416
Name:TELLO, ENRIQUE J (MD)
Entity Type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:J
Last Name:TELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ENRIQUE
Other - Middle Name:J
Other - Last Name:TELLO SILVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:60 WASHINGTON AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3271
Mailing Address - Country:US
Mailing Address - Phone:203-281-2890
Mailing Address - Fax:203-281-2896
Practice Address - Street 1:60 WASHINGTON AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3271
Practice Address - Country:US
Practice Address - Phone:203-281-2890
Practice Address - Fax:203-281-2896
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0405652084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260004862OtherMEDICARE ID PTAN
CT260004862Medicare PIN