Provider Demographics
NPI:1588766893
Name:BAEZ TELLADO, RICHARD (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:BAEZ TELLADO
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:P O BOX 801453
Mailing Address - Street 2:
Mailing Address - City:COTO LAUREL
Mailing Address - State:PR
Mailing Address - Zip Code:00780-1453
Mailing Address - Country:US
Mailing Address - Phone:787-354-2910
Mailing Address - Fax:787-848-0318
Practice Address - Street 1:2225 PONCE BY PASS
Practice Address - Street 2:OFICINA 504
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1321
Practice Address - Country:US
Practice Address - Phone:787-354-2910
Practice Address - Fax:787-848-0318
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12897208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR0090179Medicare ID - Type Unspecified
PRG97379Medicare UPIN