Provider Demographics
NPI:1790763704
Name:KELLEY, MICHAEL FREDRICK (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:FREDRICK
Last Name:KELLEY
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 1:3009A HIGHWAY 30 W
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:77340-3517
Mailing Address - Country:US
Mailing Address - Phone:512-268-0114
Mailing Address - Fax:
Practice Address - Street 1:3009A HIGHWAY 30 W
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:TX
Practice Address - Zip Code:77340-3517
Practice Address - Country:US
Practice Address - Phone:936-437-3570
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG61892083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine