Provider Demographics
NPI:1184663460
Name:KELLY, CYNTHIA S (MD)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
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:PO BOX 79137
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21279-0137
Mailing Address - Country:US
Mailing Address - Phone:757-668-7200
Mailing Address - Fax:757-668-9691
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7426
Practice Address - Fax:757-668-7784
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010508972080P0201X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890688IMedicaid
DE0000982001Medicaid
MD522500100Medicaid
VA006722083Medicaid
PA1010085990001Medicaid
WV1802398000Medicaid
VA006722083Medicaid
F84341Medicare UPIN