Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 156FX1100X | Ophthalmic | C41824 | CA |
N | 207W00000X | Ophthalmologist | C418240 | CA |
NPI | 1255351755 |
---|---|
Provider Name | Dr. Gregory Clifton Tesluk |
First Address | Modesto, CA 95355-4742 |
Second Address | Modesto, CA 95350-5365 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00C418240 | (05) | CA |
A89123 | (02) | CA |