Provider Demographics
NPI:1508943317
Name:KELLY, JAMES THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THOMAS
Last Name:KELLY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:70 N COUNTRY RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2161
Mailing Address - Country:US
Mailing Address - Phone:631-642-0609
Mailing Address - Fax:631-642-0588
Practice Address - Street 1:70 N COUNTRY RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2161
Practice Address - Country:US
Practice Address - Phone:631-642-0609
Practice Address - Fax:631-642-0588
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY173786207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY23E691Medicare ID - Type Unspecified
A61429Medicare UPIN