Provider Demographics
NPI:1164415998
Name:DAVILLIER, KELLY R (MD)
Entity Type:Individual
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First Name:KELLY
Middle Name:R
Last Name:DAVILLIER
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Gender:F
Credentials:MD
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Mailing Address - Street 1:55 HIRAM DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-1844
Mailing Address - Country:US
Mailing Address - Phone:678-945-8300
Mailing Address - Fax:770-445-2060
Practice Address - Street 1:55 HIRAM DR
Practice Address - Street 2:BUILDING B
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1844
Practice Address - Country:US
Practice Address - Phone:678-945-8300
Practice Address - Fax:770-445-2060
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2011-12-21
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Provider Licenses
StateLicense IDTaxonomies
GA060168208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1420565Medicaid
GA1899964650AMedicaid