Provider Demographics
NPI:1790031284
Name:KELLY, ERNESTO
Entity Type:Individual
Prefix:DR
First Name:ERNESTO
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 ELMSIDE DR
Mailing Address - Street 2:APT # 14
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77042-3968
Mailing Address - Country:US
Mailing Address - Phone:786-362-3934
Mailing Address - Fax:
Practice Address - Street 1:3030 ELMSIDE DR
Practice Address - Street 2:APT # 14
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77042-3968
Practice Address - Country:US
Practice Address - Phone:786-362-3934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12-173246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant