Basic Information
| Provider Information | |||||||||
| NPI: | 1477846715 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | RONAN | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 911230 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753911230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729978000 | ||||||||
| FaxNumber: | 9722342987 | ||||||||
| Practice Location | |||||||||
| Address1: | 3410 WORTH ST STE 400 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752462092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143701000 | ||||||||
| FaxNumber: | 2143701986 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2011 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R8922 | TX | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RX0202X | R8922 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology | 207RX0202X | D72295 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 048473300 | 05 | MD | MEDICAID | 392921801 | 05 | TX | MEDICAID |