Provider Demographics
NPI:1558780064
Name:KELLY, TIMOTHY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2460 N IH 35 E STE 215
Mailing Address - Street 2:
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-5271
Mailing Address - Country:US
Mailing Address - Phone:469-800-9830
Mailing Address - Fax:
Practice Address - Street 1:2460 N IH 35 E STE 215
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-5271
Practice Address - Country:US
Practice Address - Phone:469-800-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-11
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXS7696208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program