Provider Demographics
NPI:1497758825
Name:KELLY, TIMOTHY G (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:G
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 1:1915 TRADD COURT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6638
Mailing Address - Country:US
Mailing Address - Phone:910-762-0057
Mailing Address - Fax:910-762-0336
Practice Address - Street 1:1915 TRADD CT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6638
Practice Address - Country:US
Practice Address - Phone:910-762-0057
Practice Address - Fax:910-762-0336
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2013-10-18
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
NC33074207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0210JOtherBCBS
NC890210JMedicaid
NC0838871OtherUNITED HEALTHCARE
NC207802AMedicare ID - Type Unspecified
NC890210JMedicaid