Healthcare Provider Details

I. General information

NPI: 1134167455
Provider Name (Legal Business Name): STEPHEN B. KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: S. BLAKE KELLY M.D.

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13921 N MERIDIAN AVE STE 100
OKLAHOMA CITY OK
73134-1106
US

IV. Provider business mailing address

PO BOX 268938
OKLAHOMA CITY OK
73126-8938
US

V. Phone/Fax

Practice location:
  • Phone: 405-752-9600
  • Fax: 405-752-9650
Mailing address:
  • Phone: 405-752-9600
  • Fax: 405-752-9650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21242
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: