Provider Demographics
NPI:1326153941
Name:KELTY, RICHARD ALLAN (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALLAN
Last Name:KELTY
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 1:1234 E DUPONT RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-1545
Mailing Address - Country:US
Mailing Address - Phone:260-373-9700
Mailing Address - Fax:260-373-9740
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6602
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031970A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100080150Medicaid
IN000000595580OtherANTHEM
INP00698425OtherMEDICARE RR
INP00698425OtherMEDICARE RR
INC24512Medicare UPIN
IN055250RMedicare PIN