Provider Demographics
NPI:1063851509
Name:KELLY, SEAN MICHAEL (DO)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:MICHAEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:TOWNSHIP OF WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07676-4332
Mailing Address - Country:US
Mailing Address - Phone:201-280-4458
Mailing Address - Fax:
Practice Address - Street 1:606 BEECH ST
Practice Address - Street 2:
Practice Address - City:TOWNSHIP OF WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07676-4332
Practice Address - Country:US
Practice Address - Phone:201-280-4458
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT032.0132524207R00000X
MA255482207R00000X
NJ25MB10462600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine