1043256019 NPI number — DR. GREGORY PAUL KELLEY DO

Table of content: DR. GREGORY PAUL KELLEY DO (NPI 1043256019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043256019 NPI number — DR. GREGORY PAUL KELLEY DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLEY
Provider First Name:
GREGORY
Provider Middle Name:
PAUL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043256019
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14024 QUAIL POINTE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73134-1006
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-419-8447
Provider Business Mailing Address Fax Number:
405-419-7745

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13190 NE 23RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHOCTAW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73020-8621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-769-7201
Provider Business Practice Location Address Fax Number:
405-769-4034
Provider Enumeration Date:
06/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2127 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)