Provider Demographics
NPI:1477589059
Name:KELLEY DAVIS, D.O., P.A.
Entity Type:Organization
Organization Name:KELLEY DAVIS, D.O., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-374-0827
Mailing Address - Street 1:1251A E RED BIRD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-2008
Mailing Address - Country:US
Mailing Address - Phone:214-307-0827
Mailing Address - Fax:214-307-0927
Practice Address - Street 1:1251A E RED BIRD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-2008
Practice Address - Country:US
Practice Address - Phone:214-307-0827
Practice Address - Fax:214-307-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-24
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8319174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX11568320OtherCAQH
TX00W614Medicare PIN