Provider Demographics
NPI:1043223480
Name:KELLY, JOHNSON H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHNSON
Middle Name:H
Last Name:KELLY
Suffix:
Gender:M
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 1689
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:NC
Mailing Address - Zip Code:28729-1689
Mailing Address - Country:US
Mailing Address - Phone:828-891-5524
Mailing Address - Fax:828-891-4069
Practice Address - Street 1:201 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3917
Practice Address - Country:US
Practice Address - Phone:980-487-4721
Practice Address - Fax:980-487-3942
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2011-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23578208800000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC48217OtherBCBS ID
NC8948217Medicaid
NC230126OtherMEDICARE PTAN
NC23578OtherNC MEDICAL LICENSE #
NC8948217Medicaid
NC207795EMedicare PIN