Provider Demographics
NPI:1376556456
Name:WILL, KELLY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RAY
Last Name:WILL
Suffix:
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 1:11970 N CENTRAL EXPY, #510
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3768
Mailing Address - Country:US
Mailing Address - Phone:972-707-2800
Mailing Address - Fax:972-707-2801
Practice Address - Street 1:11970 N CENTRAL EXPY, #510
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3768
Practice Address - Country:US
Practice Address - Phone:972-707-2800
Practice Address - Fax:972-707-2801
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8557207LP2900X, 208VP0014X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE09472Medicare UPIN
TX80H482Medicare ID - Type Unspecified