Provider Demographics
NPI:1528038858
Name:LOBB, KELLY W (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:W
Last Name:LOBB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 4181
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77805-4181
Mailing Address - Country:US
Mailing Address - Phone:979-821-7527
Mailing Address - Fax:979-821-7528
Practice Address - Street 1:1600 JOSEPH DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1502
Practice Address - Country:US
Practice Address - Phone:979-821-7527
Practice Address - Fax:979-821-7528
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK8939208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145512301Medicaid
TX1784755600OtherUS DEPT OF LABOR
TX8AJ452OtherBLUE CROSS BLUE SHIELD OF TEXAS
TXP00017074OtherMEDICARE RAILROAD
TX4206261OtherBLUE LINK
TX00548QMedicare PIN
TXP00017074OtherMEDICARE RAILROAD