MEDICARE: KELLY JOHN WARREN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	K266750	KY
2	207N00000X	Dermatology Physician	ME133767	FL
3	207N00000X	Dermatology Physician	K8565	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1306801071	OTHER	TX	NPI

General Provider Information

NPI Number	:	1306801071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY JOHN WARREN MD

Provider Business Mailing Address
First Line	:	2110 RESEARCH ROW STE 100C
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-2519
Country	:	US
Telephone Number	:	214-845-6426
Fax Number	:	214-845-7544

Provider Business Practice Location Address
First Line	:	2110 RESEARCH ROW STE 100C
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75235-2519
Country	:	US
Telephone Number	:	214-845-6426
Fax Number	:	214-845-7544

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2006
Last Update Date	:	12/06/2024

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