Provider Demographics
NPI:1588174841
Name:SANTISTEVAN, TERA (DPM)
Entity type:Individual
Prefix:
First Name:TERA
Middle Name:
Last Name:SANTISTEVAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 W. ELGIN ST.
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012
Mailing Address - Country:US
Mailing Address - Phone:918-494-2902
Mailing Address - Fax:918-494-2905
Practice Address - Street 1:400 S. MISSION ST.
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066
Practice Address - Country:US
Practice Address - Phone:918-494-2902
Practice Address - Fax:918-494-2905
Is Sole Proprietor?:No
Enumeration Date:2017-10-01
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK368213E00000X
390200000X
125.067496390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA90772019FMedicaid