Provider Demographics
NPI:1164758892
Name:KELLY, JOHN THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
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 1:175 BLOSSOM ST UNIT 1407
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02114-2629
Mailing Address - Country:US
Mailing Address - Phone:215-527-4684
Mailing Address - Fax:
Practice Address - Street 1:175 BLOSSOM ST UNIT 1407
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2629
Practice Address - Country:US
Practice Address - Phone:215-527-4684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-31
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-077958208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice