MEDICARE: RICHARD JOSEPH KELLY 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	207Q00000X	Family Medicine Physician	F4152	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376535419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD JOSEPH KELLY MD

Provider Business Mailing Address
First Line	:	1050 E LOOP 304
Second Line	:	STE 200
City	:	CROCKETT
State	:	TX
Zip	:	75835-1814
Country	:	US
Telephone Number	:	936-544-5132
Fax Number	:	936-544-5572

Provider Business Practice Location Address
First Line	:	1050 E LOOP 304
Second Line	:	STE 200
City	:	CROCKETT
State	:	TX
Zip	:	75835-1814
Country	:	US
Telephone Number	:	936-544-5132
Fax Number	:	936-544-5572

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

Provider Enumeration Date	:	08/16/2005
Last Update Date	:	10/29/2024

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