Provider Demographics
NPI:1831272319
Name:HUMPHERYS, KELLY M (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:HUMPHERYS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:LIETZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:P.O. BOX 420
Mailing Address - Street 2:400 WYANDOTTE
Mailing Address - City:RAMONA
Mailing Address - State:OK
Mailing Address - Zip Code:74061-1337
Mailing Address - Country:US
Mailing Address - Phone:918-536-2104
Mailing Address - Fax:918-536-2203
Practice Address - Street 1:400 WYANDOTTE
Practice Address - Street 2:
Practice Address - City:RAMONA
Practice Address - State:OK
Practice Address - Zip Code:74061-1337
Practice Address - Country:US
Practice Address - Phone:918-536-2104
Practice Address - Fax:918-536-2203
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26599207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163634001Medicaid
MO206226201Medicaid
AR5N728OtherAR BLUE SHIELD #
OK200207550AMedicaid
OKPTANOK401306Medicare Oscar/Certification
MOI33282Medicare UPIN