Provider Demographics
NPI:1497704787
Name:TEDESCO, J MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:MICHAEL
Last Name:TEDESCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:610 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3702
Mailing Address - Country:US
Mailing Address - Phone:570-288-5441
Mailing Address - Fax:570-288-5842
Practice Address - Street 1:743 JEFFERSON AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-1635
Practice Address - Country:US
Practice Address - Phone:570-341-9818
Practice Address - Fax:570-341-9950
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS003900L207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABT0825767OtherDEA
PA067068Medicare PIN