Provider Demographics
NPI:1174557169
Name:TELLEZ, LUIS A (MD)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:A
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 1:26700 BROOKPARK ROAD EXT # 1
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3124
Mailing Address - Country:US
Mailing Address - Phone:440-716-0800
Mailing Address - Fax:
Practice Address - Street 1:3371 KEMP RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2514
Practice Address - Country:US
Practice Address - Phone:937-320-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-3444T207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2218068Medicaid
H09579Medicare UPIN