Provider Demographics
NPI:1871654574
Name:KELSALL, PETER J (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:KELSALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PETER
Other - Middle Name:J
Other - Last Name:KELSALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:612 N STORY RD STE 107
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-6764
Mailing Address - Country:US
Mailing Address - Phone:972-986-6885
Mailing Address - Fax:
Practice Address - Street 1:612 N STORY RD STE 107
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-6764
Practice Address - Country:US
Practice Address - Phone:972-986-6885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG0446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00PT03Medicare ID - Type Unspecified
TXB23893Medicare UPIN