Provider Demographics
NPI:1912382441
Name:MOSBURG, CALLIE (OD)
Entity Type:Individual
Prefix:DR
First Name:CALLIE
Middle Name:
Last Name:MOSBURG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 OKLAHOMA BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:ALVA
Mailing Address - State:OK
Mailing Address - Zip Code:73717-2631
Mailing Address - Country:US
Mailing Address - Phone:580-748-8007
Mailing Address - Fax:580-748-8018
Practice Address - Street 1:921 OKLAHOMA BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALVA
Practice Address - State:OK
Practice Address - Zip Code:73717
Practice Address - Country:US
Practice Address - Phone:580-748-8007
Practice Address - Fax:580-748-8018
Is Sole Proprietor?:No
Enumeration Date:2015-07-27
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2861152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist