Healthcare Provider Details

I. General information

NPI: 1568430718
Provider Name (Legal Business Name): JEAN I KEDDISSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 10TH ST OUPB 2500
OKLAHOMA CITY OK
73104-5417
US

IV. Provider business mailing address

1122 NE 13TH ST ORI 236
OKLAHOMA CITY OK
73117-1039
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-7001
  • Fax:
Mailing address:
  • Phone: 405-271-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number20091
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number20091
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: