Provider Demographics
NPI:1053544627
Name:TELLAGORRY, JAVIER ANDRES (MD)
Entity type:Individual
Prefix:DR
First Name:JAVIER
Middle Name:ANDRES
Last Name:TELLAGORRY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1 WEBSTER AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1362
Mailing Address - Country:US
Mailing Address - Phone:845-483-5934
Mailing Address - Fax:845-452-7602
Practice Address - Street 1:1 WEBSTER AVE STE 202
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1362
Practice Address - Country:US
Practice Address - Phone:845-483-5934
Practice Address - Fax:845-452-7602
Is Sole Proprietor?:No
Enumeration Date:2009-08-31
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036.141173174400000X
IL0361411732086S0129X
NY3166732086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400321616Medicare PIN