Provider Demographics
NPI:1063822633
Name:DUSTIN SHAUN TEDESCO PLLC
Entity type:Organization
Organization Name:DUSTIN SHAUN TEDESCO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-936-0504
Mailing Address - Street 1:1553 N PORTER AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6621
Mailing Address - Country:US
Mailing Address - Phone:405-217-8500
Mailing Address - Fax:405-217-8501
Practice Address - Street 1:1553 N PORTER AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6621
Practice Address - Country:US
Practice Address - Phone:405-217-8500
Practice Address - Fax:405-217-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25729207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200206650BMedicaid