Provider Demographics
NPI:1609911098
Name:RAFFERTY, KELLY R (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:R
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 W 4TH ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:YANKTON
Mailing Address - State:SD
Mailing Address - Zip Code:57078-3730
Mailing Address - Country:US
Mailing Address - Phone:605-665-0555
Mailing Address - Fax:605-665-4498
Practice Address - Street 1:1000 W 4TH ST
Practice Address - Street 2:SUITE 15
Practice Address - City:YANKTON
Practice Address - State:SD
Practice Address - Zip Code:57078-3730
Practice Address - Country:US
Practice Address - Phone:605-665-0555
Practice Address - Fax:605-665-4498
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD4270207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDF94237Medicare UPIN