Provider Demographics
NPI:1548283914
Name:TEO, BENA (MD)
Entity type:Individual
Prefix:
First Name:BENA
Middle Name:
Last Name:TEO
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 15787
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-5787
Mailing Address - Country:US
Mailing Address - Phone:949-559-6500
Mailing Address - Fax:949-559-6510
Practice Address - Street 1:6340 IRVINE BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92620
Practice Address - Country:US
Practice Address - Phone:949-559-6500
Practice Address - Fax:949-559-6510
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80908207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI21902Medicare UPIN
CAWA80908CMedicare PIN