Provider Demographics
NPI:1790951747
Name:TEDESCO, JOHN VICTOR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:VICTOR
Last Name:TEDESCO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 E 71ST ST STE 7255
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6542
Mailing Address - Country:US
Mailing Address - Phone:918-600-0026
Mailing Address - Fax:918-600-0024
Practice Address - Street 1:5555 E 71ST ST STE 7255
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6542
Practice Address - Country:US
Practice Address - Phone:918-600-0026
Practice Address - Fax:918-600-0024
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-30
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10091208600000X
OK51702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgery