Provider Demographics
NPI:1528078508
Name:TELLO, EDNA LILLIAN (MD)
Entity type:Individual
Prefix:DR
First Name:EDNA
Middle Name:LILLIAN
Last Name:TELLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1440 CORAL RIDGE DR
Mailing Address - Street 2:#121
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-5433
Mailing Address - Country:US
Mailing Address - Phone:954-632-2791
Mailing Address - Fax:954-796-6584
Practice Address - Street 1:12621 NW 8TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-4425
Practice Address - Country:US
Practice Address - Phone:954-632-2791
Practice Address - Fax:954-796-6584
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME80694208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2606259Medicaid