Provider Demographics
NPI:1962461707
Name:KELLY, OWEN L (MD)
Entity Type:Individual
Prefix:MR
First Name:OWEN
Middle Name:L
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1146
Mailing Address - Country:US
Mailing Address - Phone:479-890-5355
Mailing Address - Fax:479-890-5366
Practice Address - Street 1:401 N PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2844
Practice Address - Country:US
Practice Address - Phone:479-890-5355
Practice Address - Fax:479-890-5366
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE3477207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR182582002Medicaid
H86328Medicare UPIN
AR5G571Medicare UPIN