Provider Demographics
NPI:1275701286
Name:DODGE, KELLY LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNNE
Last Name:DODGE
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 1:464 CONGRESS AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-1361
Mailing Address - Country:US
Mailing Address - Phone:203-737-2489
Mailing Address - Fax:203-785-4580
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2259
Practice Address - Fax:203-688-5599
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT046275207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine