Provider Demographics
NPI:1790738565
Name:MCKELVY, WARREN DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:WARREN
Middle Name:DOUGLAS
Last Name:MCKELVY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 W. COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201
Mailing Address - Country:US
Mailing Address - Phone:575-625-1371
Mailing Address - Fax:575-625-1490
Practice Address - Street 1:313 W. COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201
Practice Address - Country:US
Practice Address - Phone:575-625-1371
Practice Address - Fax:575-625-1490
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM77-217208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1875Medicaid
NM1875Medicaid