Provider Demographics
NPI:1982666434
Name:PHILIP L KELTON JR MD PA
Entity Type:Organization
Organization Name:PHILIP L KELTON JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:LLEWELLYN
Authorized Official - Last Name:KELTON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:214-826-8950
Mailing Address - Street 1:3600 GASTON AVE LB-78
Mailing Address - Street 2:WADLEY TOWER SUITE 1054
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1910
Mailing Address - Country:US
Mailing Address - Phone:214-826-8950
Mailing Address - Fax:214-826-3434
Practice Address - Street 1:3600 GASTON AVE
Practice Address - Street 2:WADLEY TOWER SUITE 1054
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1910
Practice Address - Country:US
Practice Address - Phone:214-826-8950
Practice Address - Fax:214-826-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD71122086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK04616699757Medicaid
TX115836201Medicaid
00R582Medicare PIN
B23896Medicare UPIN