Provider Demographics
NPI:1346348000
Name:TELLO, TIMOTHY L (OD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:TELLO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1221 W DIVIDE AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1290
Mailing Address - Country:US
Mailing Address - Phone:701-224-0661
Mailing Address - Fax:701-224-0663
Practice Address - Street 1:1221 W DIVIDE AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1290
Practice Address - Country:US
Practice Address - Phone:701-224-0661
Practice Address - Fax:701-224-0663
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND477152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60409Medicaid
ND60409Medicaid
ND8918Medicare ID - Type Unspecified