Provider Demographics
NPI:1740311349
Name:TELLEZ, MAOXIIM (MD)
Entity type:Individual
Prefix:
First Name:MAOXIIM
Middle Name:
Last Name:TELLEZ
Suffix:
Gender:F
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:PO BOX 3428
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62708-3428
Mailing Address - Country:US
Mailing Address - Phone:800-577-5368
Mailing Address - Fax:217-757-2021
Practice Address - Street 1:1 CENTRE DR
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:IL
Practice Address - Zip Code:62675-9467
Practice Address - Country:US
Practice Address - Phone:217-632-7761
Practice Address - Fax:217-632-0312
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117662207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine