Provider Demographics
NPI:1750323747
Name:KELLY, KEVIN T (MD)
Entity Type:Individual
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First Name:KEVIN
Middle Name:T
Last Name:KELLY
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Gender:M
Credentials:MD
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Mailing Address - Street 1:6333 N FEDERAL HWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-1907
Mailing Address - Country:US
Mailing Address - Phone:954-776-6880
Mailing Address - Fax:954-229-3100
Practice Address - Street 1:1397 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-3186
Practice Address - Country:US
Practice Address - Phone:561-784-3788
Practice Address - Fax:954-229-3100
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-07-14
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Provider Licenses
StateLicense IDTaxonomies
FLME56260207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL08555OtherBLUE CROSS BLUE SHIELD
FL055262300Medicaid
FL230941OtherAVMED
FL4360358OtherAETNA
FL08555OtherBLUE CROSS BLUE SHIELD
FLE22539Medicare UPIN