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General NPI Number Information
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NPI Number | 1710322672
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Entity Type | Organization
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Legal Business Name | BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
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Dates
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Enumeration Date | 05/06/2013
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Last Update Date | 10/08/2024
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Provider Practice Location Address
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Address Line | 5050 E KENOSHA ST
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City | BROKEN ARROW
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State | OK
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Zip | 74014-6711
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Country | US
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Telephone | 918-994-5140
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Fax | 918-994-5150
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Provider Business Mailing Address
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Address Line | 5050 E KENOSHA ST
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City | BROKEN ARROW
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State | OK
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Zip | 74014-6711
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Country | US
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Telephone | 918-994-5140
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Fax | 918-994-5150
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | JACOB LEON CALLISON
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Credential | PA
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Telephone | 918-994-5140
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State | OK
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