Provider Demographics
NPI:1033146436
Name:KELLEY, SUZANNE B (MD)
Entity Type:Individual
Prefix:DR
First Name:SUZANNE
Middle Name:B
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:B
Other - Last Name:DIXSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1500 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4917
Mailing Address - Country:US
Mailing Address - Phone:817-921-3431
Mailing Address - Fax:
Practice Address - Street 1:1500 S MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4917
Practice Address - Country:US
Practice Address - Phone:817-921-3431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175531601Medicaid
TX8D8452Medicare ID - Type Unspecified
TX175531601Medicaid