Provider Demographics
NPI:1477512234
Name:KELLY, JOHN P (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
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 4540
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:NV
Mailing Address - Zip Code:89702-4540
Mailing Address - Country:US
Mailing Address - Phone:775-882-0430
Mailing Address - Fax:775-852-6902
Practice Address - Street 1:1535 MEDICAL PKWY
Practice Address - Street 2:STE B
Practice Address - City:CARSON CITY
Practice Address - State:NV
Practice Address - Zip Code:89703-4654
Practice Address - Country:US
Practice Address - Phone:775-445-7960
Practice Address - Fax:775-883-3395
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6376207RX0202X
NVNV6376207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV6376OtherMEDICAL LICENSE
NV002013294Medicaid
NVDL375ZMedicare PIN
NV6376OtherMEDICAL LICENSE