Provider Demographics
NPI:1972397222
Name:CALLAHAN, MIKAELA LIEM (OD)
Entity type:Individual
Prefix:
First Name:MIKAELA
Middle Name:LIEM
Last Name:CALLAHAN
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 COMMONWEALTH AVE APT 34
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-5609
Mailing Address - Country:US
Mailing Address - Phone:617-266-2030
Mailing Address - Fax:
Practice Address - Street 1:5520 FL-64 #101
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34208
Practice Address - Country:US
Practice Address - Phone:941-721-0649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-09
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program