Provider Demographics
NPI:1083685705
Name:KELLY, SEAN R (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:R
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 1:4747 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1804
Mailing Address - Country:US
Mailing Address - Phone:203-372-0649
Mailing Address - Fax:203-373-0376
Practice Address - Street 1:4747 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1804
Practice Address - Country:US
Practice Address - Phone:203-372-0649
Practice Address - Fax:203-373-0376
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0458782081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN