Provider Demographics
NPI:1639300932
Name:KELLY, MARK KIM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:KIM
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3707 NEW VISION DR
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1702
Mailing Address - Country:US
Mailing Address - Phone:248-787-4905
Mailing Address - Fax:
Practice Address - Street 1:3707 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1702
Practice Address - Country:US
Practice Address - Phone:248-787-4905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010950252085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology