# KELLY L WIMBERLY MD PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1578589842
- **Authorized official:** DR. KELLY L WIMBERLY MD (OWNER)
- **Authorized official phone:** (972) 239-4441

## Contact information

- **Practice address:** 17101 PRESTON RD, SUITE 200, DALLAS, TX 75248-1331
- **Practice address phone:** (972) 239-4441
- **Practice address fax:** (972) 239-1597
- **Mailing address:** 17101 PRESTON RD, SUITE 200, DALLAS, TX 75248-1331
- **Mailing address phone:** (972) 239-4441
- **Mailing address fax:** (972) 239-1597

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | J3002 | TX | Yes |

## Other

- **Enumeration date:** 07/13/2006
- **Last updated:** 07/24/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | DH1426 | MEDICARE RR GROUP NUMBER | TX |
| 01 | — | P00474586 | MEDICARE RR PIN | TX |