Provider Demographics
NPI:1548418387
Name:MATLOCK, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MATLOCK
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 1:1301 MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76450-4240
Mailing Address - Country:US
Mailing Address - Phone:254-624-7486
Mailing Address - Fax:
Practice Address - Street 1:1301 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:GRAHAM
Practice Address - State:TX
Practice Address - Zip Code:76450-4240
Practice Address - Country:US
Practice Address - Phone:254-624-7486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2014-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2643207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX321428YV79Medicare PIN