Healthcare Provider Details

I. General information

NPI: 1700113289
Provider Name (Legal Business Name): ANDREA L SESTAK MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2009
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 NW 58TH ST STE 804
OKLAHOMA CITY OK
73112-4703
US

IV. Provider business mailing address

1500 BRECKENRIDGE DR
EDMOND OK
73013-7651
US

V. Phone/Fax

Practice location:
  • Phone: 405-548-0430
  • Fax: 405-463-4408
Mailing address:
  • Phone: 405-255-4170
  • Fax: 650-727-5319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number22950
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2080P0216X
TaxonomyPediatric Rheumatology Physician
License Number22950
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: