Provider Demographics
NPI:1942491139
Name:BIRT, KELLY LYNNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:LYNNE
Last Name:BIRT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:LYNNE
Other - Last Name:SCOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:448 W 19TH ST # 667
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77008-3914
Mailing Address - Country:US
Mailing Address - Phone:281-213-5218
Mailing Address - Fax:281-746-9567
Practice Address - Street 1:27700 NORTHWEST FWY STE 330
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-6767
Practice Address - Country:US
Practice Address - Phone:281-213-5218
Practice Address - Fax:281-746-9567
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP1-0026611208600000X
TXN9678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
3870853785OtherMYUTMB 3870853785