Provider Demographics
NPI:1407855315
Name:KELLY, JOHN B (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
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 1:3505 E MERIDIAN PARK LOOP STE 100
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7242
Mailing Address - Country:US
Mailing Address - Phone:907-864-0022
Mailing Address - Fax:877-725-7371
Practice Address - Street 1:3505 E MERIDIAN PARK LOOP STE 100
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7242
Practice Address - Country:US
Practice Address - Phone:907-864-0022
Practice Address - Fax:877-725-7371
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY279532084N0400X, 208VP0014X
AK2038832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1740353Medicaid
C84878Medicare UPIN
KY0913401Medicare ID - Type Unspecified