Provider Demographics
NPI:1225026727
Name:BARRY, KELVIN A SR (DPM)
Entity Type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:A
Last Name:BARRY
Suffix:SR
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:KELVIN
Other - Middle Name:A
Other - Last Name:BARRY
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:204 GROVE AVE STE G
Mailing Address - Street 2:
Mailing Address - City:WEST DEPTFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08086-2557
Mailing Address - Country:US
Mailing Address - Phone:877-487-3338
Mailing Address - Fax:
Practice Address - Street 1:204 GROVE AVE STE G
Practice Address - Street 2:
Practice Address - City:WEST DEPTFORD
Practice Address - State:NJ
Practice Address - Zip Code:08086-2557
Practice Address - Country:US
Practice Address - Phone:877-487-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00365600213EP1101X, 213ES0000X, 213ES0103X, 213ES0131X
NYN006134213ES0103X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN006134OtherNEW YORK STATE LICENSE
NY02882406Medicaid
NJ25MD00365600OtherNEW JERSEY STATE LICENSE
V12297Medicare UPIN
NYPL2361Medicare PIN