Provider Demographics
NPI:1306927900
Name:KELLY, TODD LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:LAWRENCE
Last Name:KELLY
Suffix:
Gender:M
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:PO BOX 840853
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-0853
Mailing Address - Country:US
Mailing Address - Phone:713-620-4000
Mailing Address - Fax:
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-2164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK8775207L00000X, 207LC0200X
NC2019-00087207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX037266604Medicaid
TX8AC774OtherBLUE CROSS
LA1888397Medicaid
TX37266601Medicaid
TX037266605Medicaid
NC1306927900Medicaid
TXP00616427OtherMEDICARE RAILROAD
TX304291YK6UMedicare PIN
TX37266601Medicaid
LA1888397Medicaid
TX037266604Medicaid