Provider Demographics
NPI:1669677159
Name:O'CARROLL, KELLY FARRELL (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:FARRELL
Last Name:O'CARROLL
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 1:1200 MEDICAL PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-5653
Mailing Address - Country:US
Mailing Address - Phone:682-529-8030
Mailing Address - Fax:817-213-1734
Practice Address - Street 1:1200 MEDICAL PLAZA CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-5653
Practice Address - Country:US
Practice Address - Phone:682-529-8030
Practice Address - Fax:817-213-1734
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2219208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics