Basic Information
| Provider Information | |||||||||
| NPI: | 1568430718 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KEDDISSI | ||||||||
| FirstName: | JEAN | ||||||||
| MiddleName: | I | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 236 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 825 NE 10TH ST | ||||||||
| Address2: | OUPB 2500 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731045417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052717001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2006 | ||||||||
| LastUpdateDate: | 07/03/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0200X | 20091 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 20091 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
No ID Information.