Provider Demographics
NPI:1497814602
Name:KELLY, LUZ (MD)
Entity Type:Individual
Prefix:
First Name:LUZ
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:449 N COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-2644
Mailing Address - Country:US
Mailing Address - Phone:631-821-5651
Mailing Address - Fax:
Practice Address - Street 1:31 INDUSTRIAL BOULEVARD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11863
Practice Address - Country:US
Practice Address - Phone:631-924-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12932912084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF37980Medicare UPIN