Provider Demographics
NPI:1275592727
Name:TELLER, KATERINA (MD)
Entity Type:Individual
Prefix:
First Name:KATERINA
Middle Name:
Last Name:TELLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13420 JAMAICA AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11418-2619
Mailing Address - Country:US
Mailing Address - Phone:718-206-6742
Mailing Address - Fax:718-206-6905
Practice Address - Street 1:13420 JAMAICA AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11418-2619
Practice Address - Country:US
Practice Address - Phone:718-206-6742
Practice Address - Fax:718-206-6905
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189660207R00000X, 207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01655783Medicaid
NY0105PMMedicare ID - Type Unspecified
NY01655783Medicaid