Provider Demographics
NPI:1780686709
Name:HARMON, KELLY RENEE (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RENEE
Last Name:HARMON
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 1:6565 S YALE AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8378
Mailing Address - Country:US
Mailing Address - Phone:918-494-5170
Mailing Address - Fax:918-494-5196
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8378
Practice Address - Country:US
Practice Address - Phone:918-494-5170
Practice Address - Fax:918-494-5196
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19827208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG72665Medicare UPIN