Basic Information
| Provider Information | |||||||||
| NPI: | 1275556284 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JESUDASS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 S UTICA AVE | ||||||||
| Address2: | STE 701 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E 19TH ST | ||||||||
| Address2: | STE 600 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187481330 | ||||||||
| FaxNumber: | 9182933166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 10/25/2017 | ||||||||
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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 | 207RG0100X | 20099 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 100028320A | 05 | OK | MEDICAID |