Provider Demographics
NPI:1093334112
Name:KELLY, MEGAN CATHLEEN (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:CATHLEEN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:602-409-0499
Practice Address - Street 1:9015 N 3RD ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-2444
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-714-3755
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ70389207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ135555Medicaid