Provider Demographics
NPI:1194866434
Name:KELLY, MARIA D (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:D
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 1:1230 GROVE PARK CT
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-2840
Mailing Address - Country:US
Mailing Address - Phone:434-973-8057
Mailing Address - Fax:
Practice Address - Street 1:1230 GROVE PARK CT
Practice Address - Street 2:
Practice Address - City:EARLYSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22936-2840
Practice Address - Country:US
Practice Address - Phone:434-973-8057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010440142085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA00300000962Medicaid
VA00300000962Medicaid
VA300000962Medicare ID - Type Unspecified