Provider Demographics
NPI:1306833082
Name:KELLEY, THOMAS REYNOLDS (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:REYNOLDS
Last Name:KELLEY
Suffix:
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 1:931 N SR 434 STE 1275
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32714-7057
Mailing Address - Country:US
Mailing Address - Phone:407-635-5516
Mailing Address - Fax:407-636-7876
Practice Address - Street 1:931 N SR 434 STE 1275
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32714-7057
Practice Address - Country:US
Practice Address - Phone:407-635-5516
Practice Address - Fax:407-636-7876
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME91713207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN/AMedicaid
FLME91713OtherMEDICAL LICENSE
FL50672ZMedicare PIN
FLF94025Medicare UPIN