Provider Demographics
NPI:1154303709
Name:OFFUTT, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:OFFUTT
Suffix:
Gender:F
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:706 AVE G
Practice Address - Street 2:
Practice Address - City:MARBLE FALLS
Practice Address - State:TX
Practice Address - Zip Code:78654-5866
Practice Address - Country:US
Practice Address - Phone:830-693-8234
Practice Address - Fax:830-693-9090
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2516208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131964100OtherFIRSTCARE
TX8F9833OtherBCBS
TX80803OtherSCOTT & WHITE
TX155204401Medicaid
TX155204402Medicaid
TX155204402Medicaid
TX155204401Medicaid
TX8F9833OtherBCBS
TXTXB127381Medicare PIN