Individual
MARK L TELLEZ
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1500 S MAIN ST, SUITE 303, FORT WORTH, TX 76104-4917
(817) 702-1172
(817) 702-1605
Mailing address
PO BOX 961205, FORT WORTH, TX 76161-1205
(817) 740-8400
(817) 702-1605
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
L1214
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
140972402
—
TX
05
—
140972403
—
TX
01
—
P00308741
RAILROAD
—
Enumeration date
07/25/2006
Last updated
02/14/2017
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