Provider Demographics
NPI:1497716781
Name:KELLY, DOUGLAS A (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:154 APPLE VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-9546
Mailing Address - Country:US
Mailing Address - Phone:918-269-6936
Mailing Address - Fax:
Practice Address - Street 1:2700 DOLBEER ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95501-4736
Practice Address - Country:US
Practice Address - Phone:707-269-4229
Practice Address - Fax:707-269-3849
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK197292085R0001X
CODR00629492085R0001X
CAC1939182085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000175543Medicaid