Provider Demographics
NPI:1174508832
Name:THORSTAD, KELLY GAYLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:GAYLE
Last Name:THORSTAD
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:12174 N MO PAC EXPY
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2910
Mailing Address - Country:US
Mailing Address - Phone:512-833-7334
Mailing Address - Fax:512-833-7333
Practice Address - Street 1:12174 N MO PAC EXPY
Practice Address - Street 2:SUITE A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2910
Practice Address - Country:US
Practice Address - Phone:512-833-7334
Practice Address - Fax:512-833-7333
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2007-07-23
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Provider Licenses
StateLicense IDTaxonomies
TXL0651208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics