Provider Demographics
NPI:1497281802
Name:DE JESUS, EDITH MERCEDES (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:MERCEDES
Last Name:DE JESUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10711 E 11TH ST STE 1
Mailing Address - Street 2:XAVIER CLINIC
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-3212
Mailing Address - Country:US
Mailing Address - Phone:918-261-6493
Mailing Address - Fax:918-583-7205
Practice Address - Street 1:10711 E 11TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-3200
Practice Address - Country:US
Practice Address - Phone:918-261-6493
Practice Address - Fax:918-583-7205
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-04
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18702174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist