Provider Demographics
NPI:1811637093
Name:TESALONA, MIKKO ANGELO (MD)
Entity type:Individual
Prefix:
First Name:MIKKO
Middle Name:ANGELO
Last Name:TESALONA
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 1:222 E 111TH ST APT 8D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-3163
Mailing Address - Country:US
Mailing Address - Phone:516-697-7863
Mailing Address - Fax:
Practice Address - Street 1:95 N STATE RT 17 STE 105
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2648
Practice Address - Country:US
Practice Address - Phone:201-612-4737
Practice Address - Fax:201-689-6009
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-29
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA12736500207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty