Provider Demographics
NPI:1497757819
Name:KELLY, MARIE T (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:T
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 WEST FWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76102-7100
Mailing Address - Country:US
Mailing Address - Phone:817-877-2677
Mailing Address - Fax:
Practice Address - Street 1:2630 WEST FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76102-7100
Practice Address - Country:US
Practice Address - Phone:817-877-2677
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE68222084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00AT81Medicare ID - Type UnspecifiedMEDICARE NO.
C17798Medicare UPIN