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Organization
BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Active
Organization
BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JACOB LEON CALLISON PA (MANAGING MEMBER)
(918) 994-5140
Entity
Organization
Contact information
Practice address
5050 E KENOSHA ST, BROKEN ARROW, OK 74014-6711
(918) 994-5140
(918) 994-5150
Mailing address
5050 E KENOSHA ST, BROKEN ARROW, OK 74014-6711
(918) 994-5140
(918) 994-5150
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1487885877
NPI
OK
01
—
1700851052
NPI
OK
05
—
200520620A
—
OK
Enumeration date
05/06/2013
Last updated
10/08/2024
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