Basic Information
| Provider Information | |||||||||
| NPI: | 1467567339 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLETT | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | ALLEN | ||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | LSA/CFA/CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 594 | ||||||||
| Address2: | |||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760970594 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172958891 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1301 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042122 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178822000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | SA00126 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
No ID Information.