Provider Demographics
NPI:1073593349
Name:PHILLIPS, KELLY (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N. COLEMAN ST.
Mailing Address - Street 2:100
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078
Mailing Address - Country:US
Mailing Address - Phone:469-800-5200
Mailing Address - Fax:469-800-5210
Practice Address - Street 1:821 N. COLEMAN ST.
Practice Address - Street 2:100
Practice Address - City:PROSPER
Practice Address - State:TX
Practice Address - Zip Code:75078
Practice Address - Country:US
Practice Address - Phone:469-800-5200
Practice Address - Fax:469-800-5210
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX284974701Medicaid
TX284974701Medicaid
TXTXB136756Medicare PIN