Provider Demographics
NPI:1437184025
Name:KELLEY, NEIL R (DPM)
Entity Type:Individual
Prefix:
First Name:NEIL
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2451
Mailing Address - Country:US
Mailing Address - Phone:707-725-5223
Mailing Address - Fax:707-725-2756
Practice Address - Street 1:1730 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2451
Practice Address - Country:US
Practice Address - Phone:707-725-5223
Practice Address - Fax:707-725-2756
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000E23210213E00000X, 213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001770Medicaid
CAZZZ64278ZOtherBLUE SHIELD
CA201857499OtherBLUE CROSS
CAGRE001770Medicaid
CA201857499OtherBLUE CROSS
CAT11285Medicare UPIN