Provider Demographics
NPI:1467614636
Name:TELLERIA, MIGUEL ANGEL (MD, MBA)
Entity Type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:TELLERIA
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9066 SW 73RD CT PH 2404
Mailing Address - Street 2:
Mailing Address - City:PINECREST
Mailing Address - State:FL
Mailing Address - Zip Code:33156-2972
Mailing Address - Country:US
Mailing Address - Phone:786-808-8555
Mailing Address - Fax:786-360-1100
Practice Address - Street 1:8501 SW 124TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33183-4631
Practice Address - Country:US
Practice Address - Phone:786-808-8555
Practice Address - Fax:786-360-1100
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME121707207L00000X, 208VP0014X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015575800Medicaid