Provider Demographics
NPI:1104014299
Name:KELLY, DAVID CHARLES JR
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:CHARLES
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:BLUE ASH
Mailing Address - State:OH
Mailing Address - Zip Code:45242-7846
Mailing Address - Country:US
Mailing Address - Phone:937-232-4496
Mailing Address - Fax:
Practice Address - Street 1:8915 CHERRY ST
Practice Address - Street 2:
Practice Address - City:BLUE ASH
Practice Address - State:OH
Practice Address - Zip Code:45242-7846
Practice Address - Country:US
Practice Address - Phone:937-232-4496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHN88614682471N0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471N0900XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistNuclear Medicine Technology