Provider Demographics
NPI:1801816079
Name:BARBOUR, KELLY MCDONALD (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MCDONALD
Last Name:BARBOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:BRANDON
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2410 PAGEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113
Mailing Address - Country:US
Mailing Address - Phone:804-897-6140
Mailing Address - Fax:804-897-6141
Practice Address - Street 1:2410 PAGEHURST DR
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-6411
Practice Address - Country:US
Practice Address - Phone:804-897-6140
Practice Address - Fax:804-897-6141
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101054649207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG98855Medicare UPIN