Provider Demographics
NPI:1831105162
Name:TELLO, JORGE ENRIQUE (MD)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:ENRIQUE
Last Name:TELLO
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 1:2110 DORCHESTER AVE
Mailing Address - Street 2:SUITE 302
Mailing Address - City:DORCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:02124-5699
Mailing Address - Country:US
Mailing Address - Phone:617-698-0910
Mailing Address - Fax:617-696-3722
Practice Address - Street 1:630 ADAMS ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5631
Practice Address - Country:US
Practice Address - Phone:617-698-0910
Practice Address - Fax:617-696-3722
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA38537207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MATEM09072OtherBLUE CROSS BLUE SHIELD MA
MA2039052Medicaid
MA6359OtherHARVARD PILGRIM HC
MA038537OtherTUFTS HEALTH PLAN
MA038537OtherTUFTS HEALTH PLAN
MAM09072Medicare ID - Type Unspecified