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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