Provider Demographics
NPI:1629108881
Name:TELLEZ, GABRIEL S (IDC)
Entity Type:Individual
Prefix:MR
First Name:GABRIEL
Middle Name:S
Last Name:TELLEZ
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1626 S 31ST DR
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-5021
Mailing Address - Country:US
Mailing Address - Phone:760-271-9723
Mailing Address - Fax:
Practice Address - Street 1:1455 TICONDEROGA
Practice Address - Street 2:MCM CREW FEARLESS, COMCMRON 2, NAVAL STATION
Practice Address - City:INGLESIDE
Practice Address - State:TX
Practice Address - Zip Code:78362-5009
Practice Address - Country:US
Practice Address - Phone:760-271-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman