Provider Demographics
NPI:1760421432
Name:KELLY, THOMAS J (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:KELLY
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 1:11234 ANDERSON STREET
Mailing Address - Street 2:SUITE B623
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4000
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST STE B623
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:909-558-3905
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA533862085R0202X
CAG0737412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10540392OtherIHG/HEALTHSMART
NJ5519004Medicaid
CA1760421432Medicaid
CAP01603268OtherRAILROAD
NJKE746563Medicare ID - Type Unspecified
CACB249740Medicare PIN
CA10540392OtherIHG/HEALTHSMART