Provider Demographics
NPI:1255310587
Name:KELLY, DAVID LEE JR (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LEE
Last Name:KELLY
Suffix:JR
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-2907
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-716-2907
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11526207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC48205OtherBCBS
SCQ11526Medicaid
NC8948205Medicaid
NC26310OtherMEDCOST
NC2875OtherPARTNERS
NC4382149OtherAETNA
VA6133801Medicaid
WV204068000Medicaid
NC4382149OtherAETNA
NC26310OtherMEDCOST