Healthcare Provider Details

I. General information

NPI: 1871554139
Provider Name (Legal Business Name): KELLY VAN DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 10/14/2022
Certification Date: 10/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 W CHEROKEE ST STE H
WAGONER OK
74467-4629
US

IV. Provider business mailing address

10907 S KNOXVILLE AVE
TULSA OK
74137-6624
US

V. Phone/Fax

Practice location:
  • Phone: 918-614-5533
  • Fax: 918-485-6020
Mailing address:
  • Phone: 918-978-5588
  • Fax: 918-299-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number23418
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number23418
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number23418
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: