Provider Demographics
NPI:1063411536
Name:CALLICOAT, PAUL EDWARD JR (MD)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:EDWARD
Last Name:CALLICOAT
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 450968
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-0968
Mailing Address - Country:US
Mailing Address - Phone:918-786-7667
Mailing Address - Fax:918-786-7699
Practice Address - Street 1:900 E 13TH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2975
Practice Address - Country:US
Practice Address - Phone:918-786-7667
Practice Address - Fax:918-786-7699
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2010-05-20
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Provider Licenses
StateLicense IDTaxonomies
OK17987207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100034060AMedicaid
OK241410503Medicare ID - Type Unspecified
OK100034060AMedicaid