Provider Demographics
NPI:1053401240
Name:O'NEAL, KELLY RAMSAY III (MD, MS)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:RAMSAY
Last Name:O'NEAL
Suffix:III
Gender:M
Credentials:MD, MS
Other - Prefix:DR
Other - First Name:TREY
Other - Middle Name:
Other - Last Name:O'NEAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD, MS
Mailing Address - Street 1:1160 E 3900 S
Mailing Address - Street 2:SUITE 2000
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1202
Mailing Address - Country:US
Mailing Address - Phone:801-266-3418
Mailing Address - Fax:
Practice Address - Street 1:1160 E 3900 S
Practice Address - Street 2:SUITE 2000
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1202
Practice Address - Country:US
Practice Address - Phone:801-266-3418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5211291-1205207RC0000X
MS19720207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1323951Medicaid
5613413OtherAETNA
P00436838OtherRAILROAD MEDICARE
MS07880877Medicaid
LA1323951Medicaid