Provider Demographics
NPI:1811038060
Name:CALLISTER, MICHAEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:CALLISTER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 N 500 E
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2400
Mailing Address - Country:US
Mailing Address - Phone:435-752-0422
Mailing Address - Fax:435-792-1615
Practice Address - Street 1:1350 N 500 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2400
Practice Address - Country:US
Practice Address - Phone:435-752-0422
Practice Address - Fax:435-792-1615
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335148-1205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF71530Medicare UPIN
UT000063104Medicare PIN