Provider Demographics
NPI:1215965017
Name:TELLADO, MIGUEL (MD)
Entity type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:TELLADO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIGUEL
Other - Middle Name:
Other - Last Name:TELLADO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 100371
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0371
Mailing Address - Country:US
Mailing Address - Phone:352-265-0301
Mailing Address - Fax:352-265-0627
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0371
Practice Address - Country:US
Practice Address - Phone:352-265-0238
Practice Address - Fax:352-265-0437
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMFC1508207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL62777Medicare ID - Type Unspecified
C78171Medicare UPIN