Healthcare Provider Details

I. General information

NPI: 1235170242
Provider Name (Legal Business Name): SUSAN STABA KELLY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN LYNN STABA

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 N ORANGE AVE SUITE 589
ORLANDO FL
32804-4603
US

IV. Provider business mailing address

2501 N ORANGE AVE SUITE 589
ORLANDO FL
32804-4603
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-1300
  • Fax: 407-303-1301
Mailing address:
  • Phone: 407-303-1300
  • Fax: 407-303-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberME79161
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberM8760
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: