Provider Demographics
NPI:1023124385
Name:KELLY, MICHAEL D (DO, MBA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 CYPRESS STATION DR STE C
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-3055
Mailing Address - Country:US
Mailing Address - Phone:832-602-2030
Mailing Address - Fax:281-205-4659
Practice Address - Street 1:1125 CYPRESS STATION DR STE C
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-3055
Practice Address - Country:US
Practice Address - Phone:832-602-2030
Practice Address - Fax:281-205-4659
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4515207VG0400X, 207VX0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTPI283232102Medicaid
TXTXB164119Medicare PIN