Provider Demographics
NPI:1609833771
Name:DAVIS, KELLEY MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:MICHELLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251A E RED BIRD LN
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75241-2008
Mailing Address - Country:US
Mailing Address - Phone:214-374-0827
Mailing Address - Fax:214-374-0927
Practice Address - Street 1:1251A E RED BIRD LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75241-2008
Practice Address - Country:US
Practice Address - Phone:214-374-0827
Practice Address - Fax:214-374-0927
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8319207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F3171Medicare PIN
TXI59531Medicare UPIN