Provider Demographics
NPI:1760408066
Name:DOMSON, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:DOMSON
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 1:9834 BUSINESS WAY
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-257-1440
Mailing Address - Fax:703-257-4337
Practice Address - Street 1:500 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:VA
Practice Address - Zip Code:20186
Practice Address - Country:US
Practice Address - Phone:703-257-1440
Practice Address - Fax:703-257-4337
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051240207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E29961Medicare UPIN