Provider Demographics
NPI:1104717750
Name:KELLY, MATTHEW THOMAS
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:THOMAS
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2709 NW 159TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-1231
Mailing Address - Country:US
Mailing Address - Phone:405-696-3440
Mailing Address - Fax:
Practice Address - Street 1:2709 NW 159TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-1231
Practice Address - Country:US
Practice Address - Phone:405-696-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-11
Last Update Date:2025-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program