Provider Demographics
NPI:1063404127
Name:BENNETT, KELLY A (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:BENNETT
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 1:3601 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-8143
Mailing Address - Country:US
Mailing Address - Phone:806-743-2757
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-2757
Practice Address - Fax:806-743-2563
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0417207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA297OtherTRIWEST
OK100155840AMedicaid
TX117701603Medicaid
TX108429102OtherFIRSTCARE COMMERCIAL
TX87813GOtherBCBS
TX108429103Medicaid
TX117701602Medicaid
TX83027ZOtherHMO BLUE
NM62147OtherPRESBYTERIAN COMMERCIAL
NMT9668Medicaid
NMT9668Medicaid
TX117701602Medicaid
TX84953JMedicare ID - Type Unspecified