Provider Demographics
NPI:1235170242
Name:KELLY, SUSAN STABA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:STABA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LYNN
Other - Last Name:STABA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2501 N ORANGE AVE
Mailing Address - Street 2:SUITE 589
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-4603
Mailing Address - Country:US
Mailing Address - Phone:407-303-1300
Mailing Address - Fax:407-303-1301
Practice Address - Street 1:2501 N ORANGE AVE
Practice Address - Street 2:SUITE 589
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-4603
Practice Address - Country:US
Practice Address - Phone:407-303-1300
Practice Address - Fax:407-303-1301
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME791612080P0207X
TXM87602080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL43165YMedicare PIN
FLME79161OtherMEDICAL LICENSE
FL270327100Medicaid
I06923Medicare UPIN