Provider Demographics
NPI:1518936152
Name:KELLY, MICHAEL T (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1202 W FARM RD
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74078-2000
Mailing Address - Country:US
Mailing Address - Phone:405-744-7665
Mailing Address - Fax:405-744-6556
Practice Address - Street 1:1202 W FARM RD
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74078-2000
Practice Address - Country:US
Practice Address - Phone:405-744-7665
Practice Address - Fax:405-744-6556
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK12715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKE15988Medicare UPIN