Provider Demographics
NPI:1538153283
Name:KELLY, CRYSTAL DENISE (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:DENISE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 W GRAND PKWY S
Mailing Address - Street 2:MEMORIAL HERMANN- SOUND PHYSICIANS
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-2562
Mailing Address - Country:US
Mailing Address - Phone:281-725-5070
Mailing Address - Fax:281-725-5089
Practice Address - Street 1:17500 W GRAND PKWY S
Practice Address - Street 2:MEMORIAL HERMANN- SOUND PHYSICIANS
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-2562
Practice Address - Country:US
Practice Address - Phone:281-725-5070
Practice Address - Fax:281-725-5089
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099345208000000X
IN01055817A208000000X
TXN3785207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200273460Medicaid
IN200273460Medicaid
H10340Medicare UPIN
IL036099345Medicare ID - Type Unspecified
ILL85669Medicare ID - Type Unspecified