Provider Demographics
NPI:1134167455
Name:KELLY, STEPHEN B (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:B
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:S.
Other - Middle Name:BLAKE
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 268938
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8938
Mailing Address - Country:US
Mailing Address - Phone:405-752-9600
Mailing Address - Fax:405-752-9650
Practice Address - Street 1:13921 N MERIDIAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1106
Practice Address - Country:US
Practice Address - Phone:405-752-9600
Practice Address - Fax:405-752-9650
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2022-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21242207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK21242OtherSTATE MD LICENSE
OK100066450AMedicaid
OK249617901Medicare ID - Type Unspecified2006 NUMBER