Provider Demographics
NPI:1578670915
Name:KELLEHER, JOHN C JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
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 1:3215 HAWTHORNE DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-3415
Mailing Address - Country:US
Mailing Address - Phone:806-679-5557
Mailing Address - Fax:
Practice Address - Street 1:3215 HAWTHORNE DR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-3415
Practice Address - Country:US
Practice Address - Phone:806-679-5557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD9199208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC17766Medicare UPIN
TX00BQ46Medicare ID - Type Unspecified