Provider Demographics
NPI:1730568163
Name:TELMO, MARIEL (DPM)
Entity type:Individual
Prefix:
First Name:MARIEL
Middle Name:
Last Name:TELMO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1910 CUSTOMER CARE WAY
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-5167
Mailing Address - Country:US
Mailing Address - Phone:209-384-6542
Mailing Address - Fax:855-202-9336
Practice Address - Street 1:250 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3161
Practice Address - Country:US
Practice Address - Phone:209-239-5299
Practice Address - Fax:877-436-1494
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2019-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADPM5366213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist