Provider Demographics
NPI:1003026261
Name:KELLY, TIMOTHY RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:RICHARD
Last Name:KELLY
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 1:438 COUNTY ROAD 471
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3778
Mailing Address - Country:US
Mailing Address - Phone:662-281-0945
Mailing Address - Fax:
Practice Address - Street 1:510 AZALEA DR STE 200
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-6903
Practice Address - Country:US
Practice Address - Phone:662-236-6696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS171722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry