Provider Demographics
NPI:1972571578
Name:MAW, KELLI KHINLAY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLI
Middle Name:KHINLAY
Last Name:MAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KHIN
Other - Middle Name:LAY
Other - Last Name:MAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:300 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-3320
Mailing Address - Country:US
Mailing Address - Phone:352-540-6800
Mailing Address - Fax:352-754-4132
Practice Address - Street 1:300 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-3320
Practice Address - Country:US
Practice Address - Phone:352-540-6800
Practice Address - Fax:352-754-4132
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 82767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2618711-00Medicaid
FL2618711-00Medicaid
FLH45955 0001Medicare UPIN