Provider Demographics
NPI:1003897034
Name:KELLEY, LEROY J III (DPM)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:J
Last Name:KELLEY
Suffix:III
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WALPOLE ST FL 1
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3356
Mailing Address - Country:US
Mailing Address - Phone:781-762-4205
Mailing Address - Fax:781-255-7905
Practice Address - Street 1:24 WALPOLE ST FL 1
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062-3356
Practice Address - Country:US
Practice Address - Phone:781-762-4205
Practice Address - Fax:781-255-7905
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1496213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY70632OtherBC/BS
MA1496OtherSTATE ID
MAV09521OtherUPIN
MA042715679OtherTAX ID
MA0335797Medicaid
MALXO122OtherPTAN