Provider Demographics
NPI:1548246895
Name:CALLERY, MARK DAVID (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:DAVID
Last Name:CALLERY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-6836
Mailing Address - Country:US
Mailing Address - Phone:539-399-3410
Mailing Address - Fax:
Practice Address - Street 1:7600 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-6836
Practice Address - Country:US
Practice Address - Phone:539-399-3410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4179207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200037760AMedicaid
OK200037760AMedicaid
OKOKA105196Medicare PIN