Provider Demographics
NPI:1558446195
Name:KELLY, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:EDWARD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2401 RESEARCH BLVD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3215
Mailing Address - Country:US
Mailing Address - Phone:301-212-9200
Mailing Address - Fax:301-869-2524
Practice Address - Street 1:2401 RESEARCH BLVD
Practice Address - Street 2:SUITE 340
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3215
Practice Address - Country:US
Practice Address - Phone:301-212-9200
Practice Address - Fax:301-869-2524
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCD0006349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD11325Medicaid
MD11325Medicaid
DC173065Medicare PIN