Provider Demographics
NPI:1629117528
Name:LOVELACE, KELLI (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:LOVELACE
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:PO BOX 52588
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74152-0588
Mailing Address - Country:US
Mailing Address - Phone:918-749-2261
Mailing Address - Fax:
Practice Address - Street 1:2121 E 21ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-1409
Practice Address - Country:US
Practice Address - Phone:918-749-2261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23483207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200124080AMedicaid
P00444180OtherRAILROAD MEDICARE
7255935OtherAETNA HMO
OK23483OtherMEDICAL LICENSE
7255935OtherAETNA HMO
246723201Medicare PIN