Provider Demographics
NPI:1710322672
Name:BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Entity Type:Organization
Organization Name:BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEON
Authorized Official - Last Name:CALLISON
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:918-994-5140
Mailing Address - Street 1:5050 E KENOSHA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-6711
Mailing Address - Country:US
Mailing Address - Phone:918-994-5140
Mailing Address - Fax:918-994-5150
Practice Address - Street 1:110 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-3945
Practice Address - Country:US
Practice Address - Phone:918-994-5140
Practice Address - Fax:918-994-5150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-06
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200520620AMedicaid
OK1487885877OtherNPI
OK1700851052OtherNPI