Provider Demographics
NPI:1861560401
Name:TELLEZ, HENRY (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:TELLEZ
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 1:295 OLMSTED BLVD
Mailing Address - Street 2:MELLON BLDG. STE. 12
Mailing Address - City:PINEHURST
Mailing Address - State:NC
Mailing Address - Zip Code:28374-9131
Mailing Address - Country:US
Mailing Address - Phone:910-235-0595
Mailing Address - Fax:910-235-0546
Practice Address - Street 1:295 OLMSTED BLVD
Practice Address - Street 2:MELLON BLDG. STE. 12
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-9131
Practice Address - Country:US
Practice Address - Phone:910-235-0535
Practice Address - Fax:910-235-0546
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500740174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC130022118OtherRAIL ROAD MEDICARE
NC82328OtherBLUE CROSS BLUE SHIELD NC
NC8982328Medicaid
NC82328OtherBLUE CROSS BLUE SHIELD NC
NC130022118OtherRAIL ROAD MEDICARE