Healthcare Provider Details

I. General information

NPI: 1255920690
Provider Name (Legal Business Name): COLLYN MICHAEL KELLOGG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 STANTON L YOUNG BLVD
OKLAHOMA CITY OK
73104-5018
US

IV. Provider business mailing address

17604 HORNE LN
EDMOND OK
73012-4606
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5963
  • Fax:
Mailing address:
  • Phone: 713-213-8060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number48226
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: