Provider Demographics
NPI:1992092449
Name:KELLEY, BRIAN P (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:P
Last Name:KELLEY
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 1:1601 TRINITY ST STOP 704
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1865
Mailing Address - Country:US
Mailing Address - Phone:512-324-8320
Mailing Address - Fax:
Practice Address - Street 1:1180 SETON PKWY STE 150
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640
Practice Address - Country:US
Practice Address - Phone:512-324-8320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR8222208200000X, 2086S0122X
MI4301099164390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program