Provider Demographics
NPI:1316097108
Name:DANIEL L TALLERICO MD INC
Entity type:Organization
Organization Name:DANIEL L TALLERICO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TALLERICO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-471-6249
Mailing Address - Street 1:3863 S BOULEVARD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-471-6249
Mailing Address - Fax:405-471-6255
Practice Address - Street 1:3863 S BOULEVARD ST
Practice Address - Street 2:SUITE 100
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-5519
Practice Address - Country:US
Practice Address - Phone:405-471-6249
Practice Address - Fax:405-471-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10585207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC95554Medicare UPIN