Provider Demographics
NPI:1124056304
Name:KELLY, MARISE (MD)
Entity type:Individual
Prefix:
First Name:MARISE
Middle Name:
Last Name:KELLY
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 1:900 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77012-2127
Mailing Address - Country:US
Mailing Address - Phone:713-929-2774
Mailing Address - Fax:713-928-2781
Practice Address - Street 1:900 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77012-2127
Practice Address - Country:US
Practice Address - Phone:713-929-2774
Practice Address - Fax:713-928-2781
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ9727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX135146201Medicaid
TX135146208Medicaid
TX0052APMedicare PIN
TX135146208Medicaid
TX135146201Medicaid