Provider Demographics
NPI:1396497319
Name:KIMIKO AND TEDESCO LLC
Entity type:Organization
Organization Name:KIMIKO AND TEDESCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BREANN
Authorized Official - Middle Name:H
Authorized Official - Last Name:TEDESCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-600-0026
Mailing Address - Street 1:11911 S OXFORD AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7778
Mailing Address - Country:US
Mailing Address - Phone:918-600-0026
Mailing Address - Fax:918-600-0690
Practice Address - Street 1:11911 S OXFORD AVE STE 200
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137-7778
Practice Address - Country:US
Practice Address - Phone:918-600-0026
Practice Address - Fax:918-600-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
No2082S0099XAllopathic & Osteopathic PhysiciansPlastic SurgeryPlastic Surgery Within the Head and NeckGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1790951747OtherCOMMUNITY CARE
OK1790951747Medicaid
OK1790951747OtherAETNA
OK1790951747OtherPHCS
OK1790951747OtherUNITED HEALTHCARE
OK1790951747OtherBLUE CROSS BLUE SHIELD
OK1790951747OtherVA
OK1790951747OtherCIGNA
OK1790951747OtherPREFERED COMMUNITY CHOICE
OK1790951747OtherGLOBAL HEALTH
OK1790951747OtherHEALTH CHOICE