Provider Demographics
NPI:1720122583
Name:KELLY, CHRISTOPHER P (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11464 S PARKWAY PLAZA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-6053
Mailing Address - Country:US
Mailing Address - Phone:801-987-8653
Mailing Address - Fax:
Practice Address - Street 1:11464 S PARKWAY PLAZA DR STE 300
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-6053
Practice Address - Country:US
Practice Address - Phone:801-987-8653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9258138-12052086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery