Provider Demographics
NPI:1871554139
Name:DAVIS, KELLY VAN (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:VAN
Last Name:DAVIS
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 1:10907 S KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-6624
Mailing Address - Country:US
Mailing Address - Phone:918-978-5588
Mailing Address - Fax:918-299-0323
Practice Address - Street 1:1202 W CHEROKEE ST STE H
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4629
Practice Address - Country:US
Practice Address - Phone:918-614-5533
Practice Address - Fax:918-485-6020
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23418207RE0101X, 207RR0500X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200077080AMedicaid
OK731297740OtherTAX ID #
OK7591838OtherAETNA EDI #
OKI54715Medicare UPIN
OK247619901Medicare ID - Type Unspecified