Provider Demographics
NPI:1427004704
Name:KELLEY, MARK C (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:C
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SUNSET DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRENADA
Mailing Address - State:MS
Mailing Address - Zip Code:38901-4086
Mailing Address - Country:US
Mailing Address - Phone:662-227-4463
Mailing Address - Fax:662-226-5257
Practice Address - Street 1:1300 SUNSET DR
Practice Address - Street 2:SUITE A
Practice Address - City:GRENADA
Practice Address - State:MS
Practice Address - Zip Code:38901-4086
Practice Address - Country:US
Practice Address - Phone:662-227-4463
Practice Address - Fax:662-226-5257
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16693207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G91414Medicare UPIN
MS512I080025Medicare PIN