Healthcare Provider Details

I. General information

NPI: 1427498211
Provider Name (Legal Business Name): TERESA JEAN ROBERTS M.ED.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 06/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PLAZA SOUTH ST
TAHLEQUAH OK
74464-4750
US

IV. Provider business mailing address

1 PLAZA SOUTH ST
TAHLEQUAH OK
74464-4750
US

V. Phone/Fax

Practice location:
  • Phone: 918-443-0605
  • Fax:
Mailing address:
  • Phone: 918-443-0605
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number135739
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: