Healthcare Provider Details

I. General information

NPI: 1316174675
Provider Name (Legal Business Name): KELLY MARAK D.O., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2009
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

IV. Provider business mailing address

1400 E DOWNING ST
TAHLEQUAH OK
74464-3324
US

V. Phone/Fax

Practice location:
  • Phone: 918-456-0641
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number240394
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number5679
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: