Provider Demographics
NPI:1518042167
Name:PO, TEDMUND GLEN (MD)
Entity type:Individual
Prefix:
First Name:TEDMUND
Middle Name:GLEN
Last Name:PO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4302
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-778-9472
Practice Address - Street 1:5549 VAN BUREN BLVD
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-2068
Practice Address - Country:US
Practice Address - Phone:951-324-5901
Practice Address - Fax:877-778-9472
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83322207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01282953/DU4034OtherRAILROAD MEDICARE
CABN513XMedicare PIN
CAWA83322BMedicare PIN
CABN513WMedicare PIN
CAP01282953/DU4034OtherRAILROAD MEDICARE
CABN513YMedicare PIN
CABN513TMedicare PIN