Provider Demographics
NPI:1275715161
Name:DOUGLAS J. KELLEY, INC.
Entity Type:Organization
Organization Name:DOUGLAS J. KELLEY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:609-748-2288
Mailing Address - Street 1:308 S NEW YORK RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9650
Mailing Address - Country:US
Mailing Address - Phone:609-748-2288
Mailing Address - Fax:609-748-8866
Practice Address - Street 1:308 S NEW YORK RD UNIT D
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9650
Practice Address - Country:US
Practice Address - Phone:609-748-2288
Practice Address - Fax:609-748-8866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00507000332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4972790001Medicare NSC
NJU38629Medicare UPIN
NJ136664Medicare PIN