Provider Demographics
NPI:1053544783
Name:KELLY, KATHRYN MARIE COUTURE (MD)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE COUTURE
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:
Practice Address - Street 1:3003 W DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:CHRONIC COMPLEX CLINIC
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6307
Practice Address - Country:US
Practice Address - Phone:813-554-8121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-28
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01071090A208000000X
FLME121201208M00000X
FLME121021208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14T3POtherBLUE CROSS BLUE SHIELD
FL014414200Medicaid
FLHZ432YMedicare PIN