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General NPI Number Information
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NPI Number | 1871554139
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Entity Type | Individual
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Provider Name | KELLY VAN DAVIS M.D.
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Gender | Male
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Dates
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Enumeration Date | 03/28/2006
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Last Update Date | 10/14/2022
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Provider Practice Location Address
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Address Line | 1202 W CHEROKEE ST STE H
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City | WAGONER
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State | OK
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Zip | 74467-4629
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Country | US
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Telephone | 918-614-5533
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Fax | 918-485-6020
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Provider Business Mailing Address
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Address Line | 10907 S KNOXVILLE AVE
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City | TULSA
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State | OK
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Zip | 74137-6624
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Country | US
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Telephone | 918-978-5588
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Fax | 918-299-0323
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 23418
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License Number State | OK
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Taxonomy #2
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Taxonomy Code | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | 23418
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License Number State | OK
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Taxonomy #3
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 23418
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License Number State | OK
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