Provider Demographics
NPI:1518162650
Name:HUTCHESON, KELLEY A (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:HUTCHESON
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 1:5909 LUTHER LN APT 1906
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75225-5913
Mailing Address - Country:US
Mailing Address - Phone:919-949-2661
Mailing Address - Fax:
Practice Address - Street 1:4716 ALLIANCE BLVD, PAVILION II
Practice Address - Street 2:SUITE 310
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-1010
Practice Address - Country:US
Practice Address - Phone:469-800-6200
Practice Address - Fax:469-800-6210
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP6646208G00000X
MO2011015965208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3342834-01Medicaid