Provider Demographics
NPI:1407820939
Name:KELLY, GARRETT (MD)
Entity Type:Individual
Prefix:
First Name:GARRETT
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:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1168 FIRST COLONIAL RD
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2444
Practice Address - Country:US
Practice Address - Phone:757-352-2020
Practice Address - Fax:757-686-0541
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102036923207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA171965OtherANTHEM
VA541595397OtherMID ATLANTIC SOLUTIONS
VA122066OtherSENTARA/OPTIMA
VA010021235Medicaid
VA541595397OtherCIGNA
VA541595397OtherPRIVATE HEALTHCARE SYSTEM
VA4084676OtherAETNA
VA541595397OtherVIRGINIA HEALTH NETWORK
002928B28Medicare PIN
VA122066OtherSENTARA/OPTIMA