Provider Demographics
NPI:1598721755
Name:KELLY, STEPHANIE ELAINE (DO)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ELAINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ELAINE
Other - Last Name:SUMMERS, KUELING, DEGIUSTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5801 E 41ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5618
Mailing Address - Country:US
Mailing Address - Phone:918-743-8943
Mailing Address - Fax:918-743-8552
Practice Address - Street 1:5801 E 41ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5618
Practice Address - Country:US
Practice Address - Phone:918-743-8943
Practice Address - Fax:918-743-8552
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-2464-212085R0202X
OK37492085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200031830BMedicaid
OKP00449126Medicare PIN
OK200031830BMedicaid
OK246736503Medicare PIN
OK246736504Medicare PIN
I15602Medicare UPIN
OKOKA100765Medicare PIN
OKOKA100766Medicare PIN
OK246736502Medicare PIN