Provider Demographics
NPI:1740713254
Name:MAYRAND, KELSEY (MD)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:MAYRAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2261 PHILADELPHIA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45406-1814
Mailing Address - Country:US
Mailing Address - Phone:937-734-4141
Mailing Address - Fax:937-277-7249
Practice Address - Street 1:1244 MEADOW BRIDGE DR STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-6388
Practice Address - Country:US
Practice Address - Phone:937-208-7600
Practice Address - Fax:937-208-7620
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.139593207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0405964Medicaid