Provider Demographics
NPI:1518253418
Name:KELLEHER, MICHAEL S JR (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:S
Last Name:KELLEHER
Suffix:JR
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 1:2 JEREMY GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:CT
Mailing Address - Zip Code:06525-2044
Mailing Address - Country:US
Mailing Address - Phone:860-620-7298
Mailing Address - Fax:
Practice Address - Street 1:1591 BOSTON POST RD STE 106
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-4335
Practice Address - Country:US
Practice Address - Phone:203-453-5123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT549742085P0229X, 2085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program