Provider Demographics
NPI:1528023652
Name:KELLY, CARLA J (DO)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:J
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 N 12TH ST
Mailing Address - Street 2:SUITE 3102
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1308
Mailing Address - Country:US
Mailing Address - Phone:414-219-5000
Mailing Address - Fax:
Practice Address - Street 1:1020 N 12TH ST
Practice Address - Street 2:SUITE 3102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1308
Practice Address - Country:US
Practice Address - Phone:414-219-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52317207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT160002229Medicare UPIN
CTI23976Medicare ID - Type Unspecified