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NPI Code Detail

MEDICARE: BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC

MEDICARE: BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207Q00000XFamily Medicine PhysicianOK

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
21700851052OTHEROKNPI
31487885877OTHEROKNPI

General Provider Information

NPI Number : 1710322672
Entity Type Code : Organization
Provider Name (Legal Business Name) : BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Provider Business Mailing Address
First Line : 5050 E KENOSHA ST
Second Line :
City : BROKEN ARROW
State : OK
Zip : 74014-6711
Country : US
Telephone Number : 918-994-5140
Fax Number : 918-994-5150
Provider Business Practice Location Address
First Line : 5050 E KENOSHA ST
Second Line :
City : BROKEN ARROW
State : OK
Zip : 74014-6711
Country : US
Telephone Number : 918-994-5140
Fax Number : 918-994-5150
Authorized Official
Title or Position : MANAGING MEMBER
Name : JACOB LEON CALLISON
Credential : PA
Telephone Number : 918-994-5140
Provider Enumeration Date : 05/06/2013
Last Update Date : 10/08/2024

Similar Medicare Providers

1487885877 — JACOB LEON CALLISON PA
Practice Location Address:
5050 E KENOSHA ST
BROKEN ARROW, OK
74014-6711
Practice Phone: 918-994-5140
Practice Fax: 918-994-5150
1457711038 — ROBBIE MICHELLE BOLLINGER PA-C
Practice Location Address:
5050 E KENOSHA ST
BROKEN ARROW, OK
74014-6711
Practice Phone: 918-994-5140
Practice Fax: 918-994-5150
1609316264 — TIFFANY TYLER APRN-CNP
Practice Location Address:
5050 E KENOSHA ST
BROKEN ARROW, OK
74014-6711
Practice Phone: 918-335-9492
Practice Fax:
1265003123 — ASHLEY NICOLE TURNER
Practice Location Address:
5050 E KENOSHA ST
BROKEN ARROW, OK
74014-6711
Practice Phone: 918-994-5140
Practice Fax:
1467384495 — LLOYD COLVIN
Practice Location Address:
2310 S BEECH CT
BROKEN ARROW, OK
74012-6711
Practice Phone: 918-693-4531
Practice Fax:
1407788839 — MIRIAM FAITH NANTUMBWE RN
Practice Location Address:
2548 E KENOSHA ST
BROKEN ARROW, OK
74014-6712
Practice Phone: 918-355-0993
Practice Fax: 918-355-0995

Directions to “BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC ” Practice Location

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