Healthcare Provider Details

I. General information

NPI: 1457461956
Provider Name (Legal Business Name): MARK TRAVIS CALLESEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 11/21/2025
Certification Date: 11/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 E BASELINE RD STE 5
PHOENIX AZ
85042-6536
US

IV. Provider business mailing address

3101 N CENTRAL AVE STE 550
PHOENIX AZ
85012-2635
US

V. Phone/Fax

Practice location:
  • Phone: 602-230-7373
  • Fax: 602-441-5836
Mailing address:
  • Phone: 602-230-7373
  • Fax: 602-682-7455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number23058
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: