Provider Demographics
NPI:1144201799
Name:SMITH, KELLY (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13400 E SHEA BLVD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-5452
Mailing Address - Country:US
Mailing Address - Phone:480-301-8000
Mailing Address - Fax:
Practice Address - Street 1:13400 E SHEA BLVD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85259-5452
Practice Address - Country:US
Practice Address - Phone:480-301-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97602208600000X
AZ497802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicare UPIN