MEDICARE: KELLY VAN DAVIS M.D.

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
1	207RE0101X	Endocrinology, Diabetes & Metabolism Physician	23418	OK
2	207RR0500X	Rheumatology Physician	23418	OK
3	207R00000X	Internal Medicine Physician	23418	OK

General Provider Information

NPI Number	:	1871554139
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY VAN DAVIS M.D.

Provider Business Mailing Address
First Line	:	10907 S KNOXVILLE AVE
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74137-6624
Country	:	US
Telephone Number	:	918-978-5588
Fax Number	:	918-299-0323

Provider Business Practice Location Address
First Line	:	1202 W CHEROKEE ST STE H
Second Line	:
City	:	WAGONER
State	:	OK
Zip	:	74467-4629
Country	:	US
Telephone Number	:	918-614-5533
Fax Number	:	918-485-6020

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	10/14/2022

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