=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669677159
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY FARRELL O'CARROLL MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2007
-----------------------------------------------------
Last Update Date | 03/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-5653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-529-8030
-----------------------------------------------------
Fax | 817-213-1734
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1200 MEDICAL PLAZA CT
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-5653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-529-8030
-----------------------------------------------------
Fax | 817-213-1734
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | N2219
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | N2219
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------