Provider Demographics
NPI:1427299346
Name:MUTCH, KELLY RAY (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RAY
Last Name:MUTCH
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 1:62462 IGO LN
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-5147
Mailing Address - Country:US
Mailing Address - Phone:541-963-9732
Mailing Address - Fax:
Practice Address - Street 1:62462 IGO LN
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-5147
Practice Address - Country:US
Practice Address - Phone:541-963-9732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-23
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15980207R00000X
IDM-4837207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine