Provider Demographics
NPI:1316566565
Name:KELLY, KRISTOPHER (MD)
Entity Type:Individual
Prefix:
First Name:KRISTOPHER
Middle Name:
Last Name:KELLY
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 1:281 LINCOLN ST STE HM2-212
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2138
Mailing Address - Country:US
Mailing Address - Phone:508-334-8015
Mailing Address - Fax:508-334-8235
Practice Address - Street 1:55 LAKE AVE N
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01655-0002
Practice Address - Country:US
Practice Address - Phone:508-334-8015
Practice Address - Fax:508-334-8235
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program