Provider Demographics
NPI:1073770657
Name:CARY, KELLY CLINT (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CLINT
Last Name:CARY
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:535 BARNHILL DR
Practice Address - Street 2:STE 420
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5112
Practice Address - Country:US
Practice Address - Phone:317-278-1979
Practice Address - Fax:317-278-1981
Is Sole Proprietor?:No
Enumeration Date:2008-05-21
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064976A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000824269OtherANTHEM BCBS PIN
IN201182630Medicaid
IN064740003Medicare PIN