Healthcare Provider Details

I. General information

NPI: 1972207371
Provider Name (Legal Business Name): WILLIAM TEDJO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333B RED WOLF BLVD
JONESBORO AR
72405-9739
US

IV. Provider business mailing address

333B RED WOLF BLVD
JONESBORO AR
72405-9739
US

V. Phone/Fax

Practice location:
  • Phone: 870-972-2054
  • Fax:
Mailing address:
  • Phone: 870-972-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License NumberE-20912
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: