Provider Demographics
NPI:1417376476
Name:KELLEY, MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
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 1:10807 FALLS RD UNIT 87
Mailing Address - Street 2:
Mailing Address - City:BROOKLANDVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21022-7504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:410-261-8085
Practice Address - Street 1:41 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-9835
Practice Address - Country:US
Practice Address - Phone:802-334-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD87596208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery