Provider Demographics
NPI:1497787873
Name:GRIMES, KELLY DAMON (DO)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DAMON
Last Name:GRIMES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3437 W 7TH ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-2718
Mailing Address - Country:US
Mailing Address - Phone:817-797-6599
Mailing Address - Fax:817-735-8049
Practice Address - Street 1:3437 W 7TH ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2718
Practice Address - Country:US
Practice Address - Phone:817-797-6599
Practice Address - Fax:817-735-8049
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK7749207Q00000X, 2083P0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX144815104Medicaid
TX0056PJOtherBCBS
TXH17597Medicare UPIN
TX144815104Medicaid