Provider Demographics
NPI:1902140262
Name:MANUEL TELLEZ, D.O., P.A.
Entity Type:Organization
Organization Name:MANUEL TELLEZ, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESDIENT
Authorized Official - Prefix:
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TELLEZ
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:179-462-3318
Mailing Address - Street 1:3540 E BROAD ST STE 120-259
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5633
Mailing Address - Country:US
Mailing Address - Phone:817-946-2331
Mailing Address - Fax:
Practice Address - Street 1:3500 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3460
Practice Address - Country:US
Practice Address - Phone:214-947-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-26
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty