Healthcare Provider Details

I. General information

NPI: 1376556456
Provider Name (Legal Business Name): KELLY RAY WILL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7515 GREENVILLE AVE STE 500
DALLAS TX
75231-3849
US

IV. Provider business mailing address

11970 N CENTRAL EXPY, #510
DALLAS TX
75243-3768
US

V. Phone/Fax

Practice location:
  • Phone: 972-777-6101
  • Fax: 972-833-2005
Mailing address:
  • Phone: 972-707-2800
  • Fax: 972-707-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG8557
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberG8667
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberG8557
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberG8557
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: