Provider Demographics
NPI:1669632881
Name:KELLY, JOEL DANIEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:DANIEL
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E GUDE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-1496
Mailing Address - Country:US
Mailing Address - Phone:301-933-7133
Mailing Address - Fax:301-933-7137
Practice Address - Street 1:1031 W WILLIAMS ST
Practice Address - Street 2:SUITE 105A
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-3955
Practice Address - Country:US
Practice Address - Phone:919-363-3310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC601213ES0103X
NY65006321213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNCF165B699Medicare PIN