Provider Demographics
NPI:1275556284
Name:JESUDASS, RICHARD ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ROBERT
Last Name:JESUDASS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:STE 701
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4019
Mailing Address - Country:US
Mailing Address - Phone:918-832-6049
Mailing Address - Fax:918-832-6055
Practice Address - Street 1:1725 E 19TH ST
Practice Address - Street 2:STE 600
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-748-1330
Practice Address - Fax:918-293-3166
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20099207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100028320AMedicaid
OKOKA101612Medicare PIN