Provider Demographics
NPI:1487626313
Name:MCCALLA, KIT C (DO, MBA)
Entity Type:Individual
Prefix:
First Name:KIT
Middle Name:C
Last Name:MCCALLA
Suffix:
Gender:M
Credentials:DO, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1189
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97339-1189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3620 NW SAMARITAN DR STE 202
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3785
Practice Address - Country:US
Practice Address - Phone:541-768-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-04
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI147-321207X00000X
AZ3671207X00000X
ORDO169772207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ596 009Medicaid
AZZ 119 971OtherMEDICARE
AZ596 009Medicaid