Provider Demographics
NPI:1477906915
Name:KELLY, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
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 1:661 E ALTAMONTE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-5102
Mailing Address - Country:US
Mailing Address - Phone:407-303-5191
Mailing Address - Fax:407-303-5193
Practice Address - Street 1:661 E ALTAMONTE DR STE 220
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-5102
Practice Address - Country:US
Practice Address - Phone:407-303-5191
Practice Address - Fax:407-303-5193
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME134463208C00000X
FLTRN22550390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program