Provider Demographics
NPI:1902855430
Name:KELT, SIDNEY A JR (MD)
Entity Type:Individual
Prefix:DR
First Name:SIDNEY
Middle Name:A
Last Name:KELT
Suffix:JR
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 1:3500 OAKLAWN AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-4349
Mailing Address - Country:US
Mailing Address - Phone:972-709-1961
Mailing Address - Fax:
Practice Address - Street 1:3500 OAKLAWN AVE
Practice Address - Street 2:STE 300
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-4349
Practice Address - Country:US
Practice Address - Phone:972-709-1961
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH16012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113854702Medicaid
TX752484883OtherTAX ID #
TX00A32XOtherBCBS PROVIDER #
TX00A32XOtherBCBS PROVIDER #
TX113854702Medicaid
TX00A32XMedicare ID - Type UnspecifiedMEDICARE PROVIDER #