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General NPI Number Information
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NPI Number | 1063822633
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Entity Type | Organization
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Legal Business Name | DUSTIN SHAUN TEDESCO PLLC
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Dates
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Enumeration Date | 05/05/2014
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Last Update Date | 05/05/2014
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Provider Practice Location Address
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Address Line | 1553 N PORTER AVE
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City | NORMAN
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State | OK
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Zip | 73071-6621
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Country | US
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Telephone | 405-217-8500
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Fax | 405-217-8501
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Provider Business Mailing Address
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Address Line | 1553 N PORTER AVE
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City | NORMAN
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State | OK
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Zip | 73071-6621
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Country | US
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Telephone | 405-217-8500
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Fax | 405-217-8501
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | SHAUN TEDESCO
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Credential | MD
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Telephone | 405-936-0504
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RN0300X
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Taxonomy Name | Nephrology Physician
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License Number | 25729
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License Number State | OK
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