Provider Demographics
NPI:1598769333
Name:KELLY, ALLAN ROWAN (MD)
Entity Type:Individual
Prefix:
First Name:ALLAN
Middle Name:ROWAN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1275 W. TERRELL AVE
Mailing Address - Street 2:#200
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-250-7035
Mailing Address - Fax:817-250-0119
Practice Address - Street 1:1275 W. TERRELL AVE
Practice Address - Street 2:#200
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-250-7035
Practice Address - Fax:817-250-0119
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG6952207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX114883503Medicaid
TXC17794Medicare UPIN
TX00GG80Medicare PIN