Provider Demographics
NPI:1639166317
Name:LAWRENCE D KELLEY
Entity Type:Organization
Organization Name:LAWRENCE D KELLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:DELANO
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-767-8500
Mailing Address - Street 1:587 E STATE ROAD 434
Mailing Address - Street 2:SUITE 1071
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-5201
Mailing Address - Country:US
Mailing Address - Phone:407-767-8500
Mailing Address - Fax:407-767-6999
Practice Address - Street 1:587 E STATE ROAD 434
Practice Address - Street 2:SUITE 1071
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-5201
Practice Address - Country:US
Practice Address - Phone:407-767-8500
Practice Address - Fax:407-767-6999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0650Medicare ID - Type UnspecifiedGROUP NUMBER