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General NPI Number Information
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NPI Number | 1164767018
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Entity Type | Organization
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Legal Business Name | JOHN V TEDESCO DO PA
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Dates
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Enumeration Date | 12/04/2012
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Last Update Date | 12/04/2012
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Provider Practice Location Address
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Address Line | 209 S 36TH ST SUITE A
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City | MUSKOGEE
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State | OK
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Zip | 74401-5043
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Country | US
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Telephone | 918-913-9513
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Fax | 918-913-9515
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Provider Business Mailing Address
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Address Line | 209 S 36TH ST SUITE A
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City | MUSKOGEE
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State | OK
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Zip | 74401-5043
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Country | US
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Telephone | 918-913-9513
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Fax | 918-913-9515
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Authorized Official
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Title or Position | OWNER
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Name | JOHN V TEDESCO
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Credential | DO
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Telephone | 918-913-9513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State | OK
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