Provider Demographics
NPI:1376565820
Name:KELLEY, RICHARD DWAIN (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:DWAIN
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RICHARD
Other - Middle Name:DWAIN
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3401 ALDWYCHE DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5913
Mailing Address - Country:US
Mailing Address - Phone:512-569-4457
Mailing Address - Fax:
Practice Address - Street 1:13435 N HWY 183 STE 311
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-3258
Practice Address - Country:US
Practice Address - Phone:512-614-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL6457207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160443101Medicaid
TXP00051944Medicare PIN
TX8A9724Medicare PIN
TX160443101Medicaid