Provider Demographics
NPI:1255351755
Name:TESLUK, GREGORY CLIFTON (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CLIFTON
Last Name:TESLUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 WYCLIFFE DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4742
Mailing Address - Country:US
Mailing Address - Phone:209-526-5121
Mailing Address - Fax:
Practice Address - Street 1:400 E ORANGEBURG AVE STE 2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5365
Practice Address - Country:US
Practice Address - Phone:209-526-3000
Practice Address - Fax:209-526-3133
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC41824156FX1100X
CAC418240207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Not Answered207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C418240Medicaid
CAA89123Medicare UPIN
CA00C418240Medicare ID - Type Unspecified