Provider Demographics
NPI:1285783696
Name:MILLER, KELLY (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:103 E FREY ST STE 101
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-2603
Practice Address - Country:US
Practice Address - Phone:254-918-2484
Practice Address - Fax:254-965-3294
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6487208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH17772Medicare UPIN
TX87083JMedicare ID - Type Unspecified