Healthcare Provider Details

I. General information

NPI: 1093862088
Provider Name (Legal Business Name): COLIN K KELLY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MARY M KELLY M.D.

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 03/12/2020
Certification Date: 03/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4132 E MORRISON RANCH PKWY
GILBERT AZ
85296-3093
US

IV. Provider business mailing address

4132 E MORRISON RANCH PKWY
GILBERT AZ
85296-3093
US

V. Phone/Fax

Practice location:
  • Phone: 801-560-9613
  • Fax:
Mailing address:
  • Phone: 801-560-9613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number55007
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: