Provider Demographics
NPI:1629156427
Name:O'NEAL, KELLY C (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:O'NEAL
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 1:216 14TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SIDNEY
Mailing Address - State:MT
Mailing Address - Zip Code:59270-3519
Mailing Address - Country:US
Mailing Address - Phone:406-488-2100
Mailing Address - Fax:406-488-2125
Practice Address - Street 1:214 14TH AVE SW
Practice Address - Street 2:
Practice Address - City:SIDNEY
Practice Address - State:MT
Practice Address - Zip Code:59270-3521
Practice Address - Country:US
Practice Address - Phone:406-488-2100
Practice Address - Fax:406-488-2125
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52153208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT40305OtherSTATE LICENSE
CA00G521530Medicaid
CA00G521530Medicaid