Provider Demographics
NPI:1326253832
Name:CALLISON, RICHARD CHARLES JR (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:CHARLES
Last Name:CALLISON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2402 FRIST BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4838
Mailing Address - Country:US
Mailing Address - Phone:772-460-8838
Mailing Address - Fax:772-460-8808
Practice Address - Street 1:2402 FRIST BLVD STE 201
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4838
Practice Address - Country:US
Practice Address - Phone:772-460-8838
Practice Address - Fax:772-460-8808
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20100115532084N0400X, 2084V0102X, 2085R0204X
FLME1414542084N0400X, 2085R0204X, 2084V0102X
IA372382084N0400X, 2084V0102X, 2085R0204X
MO20030259202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00671070Medicare PIN
IAI09230008Medicare PIN
MO135720049Medicare PIN