Provider Demographics
NPI:1629017322
Name:CARUSO, KELLY SHANNON (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SHANNON
Last Name:CARUSO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SHANNON
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:1100 MONTOUR RD
Practice Address - Street 2:
Practice Address - City:LOYSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17047-9200
Practice Address - Country:US
Practice Address - Phone:717-789-3553
Practice Address - Fax:717-789-3198
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009531L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018455660004Medicaid
PA0018455660004Medicaid
PA0018455660004Medicaid