Provider Demographics
NPI:1225263114
Name:KELSO, WILLIAM R II (MD,)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:KELSO
Suffix:II
Gender:M
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 1479
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1479
Mailing Address - Country:US
Mailing Address - Phone:229-227-5510
Mailing Address - Fax:229-227-5527
Practice Address - Street 1:454 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5535
Practice Address - Country:US
Practice Address - Phone:229-227-5510
Practice Address - Fax:229-227-5527
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA023175208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
D45829Medicare UPIN