Provider Demographics
NPI:1114943990
Name:KELLEY, ROGER EVERETT (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:EVERETT
Last Name:KELLEY
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 1:131 S. ROBERTSON STREET, STE. 1300
Mailing Address - Street 2:CENTER FOR CLINICAL NEUROSCIENCES
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70112
Mailing Address - Country:US
Mailing Address - Phone:504-988-1133
Mailing Address - Fax:504-988-9191
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0136862084N0400X
LAMD.0136862084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1653071Medicaid
LA1653071Medicaid
LAE12077Medicare UPIN