Provider Demographics
NPI:1679860019
Name:KELLEY, GLEN DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:GLEN
Middle Name:DAVID
Last Name:KELLEY
Suffix:
Gender:M
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:PO BOX 678504
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8504
Mailing Address - Country:US
Mailing Address - Phone:303-349-0935
Mailing Address - Fax:817-284-3425
Practice Address - Street 1:1001 W MINERAL AVE
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80120-4507
Practice Address - Country:US
Practice Address - Phone:303-334-1100
Practice Address - Fax:817-284-3425
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-06
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO37410208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation