Provider Demographics
NPI:1194008375
Name:KELLY, CRYSTAL (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:KELLY
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 1:205 E UNIVERSITY AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78626-6814
Mailing Address - Country:US
Mailing Address - Phone:877-800-5722
Mailing Address - Fax:
Practice Address - Street 1:1900 SCENIC DR
Practice Address - Street 2:3326
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78626-7724
Practice Address - Country:US
Practice Address - Phone:877-700-5722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-23
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0986207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2988644-01Medicaid