Provider Demographics
NPI:1518978063
Name:TELLO, CARLOS A (MD PA)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:A
Last Name:TELLO
Suffix:
Gender:M
Credentials:MD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2246
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07509-2246
Mailing Address - Country:US
Mailing Address - Phone:973-904-0100
Mailing Address - Fax:973-595-8286
Practice Address - Street 1:356 TOTOWA AVE
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07502-2137
Practice Address - Country:US
Practice Address - Phone:973-904-0100
Practice Address - Fax:973-595-8286
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA047031002086S0129X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3736008Medicaid
NJB79618Medicare UPIN
NJ3736008Medicaid