Provider Demographics
NPI:1780666560
Name:KELLEY, WILLIAM R JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:R
Last Name:KELLEY
Suffix:JR
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 1:4825 HWY 95
Mailing Address - Street 2:
Mailing Address - City:FORT MOHAVE
Mailing Address - State:AZ
Mailing Address - Zip Code:86426-8315
Mailing Address - Country:US
Mailing Address - Phone:760-326-7225
Mailing Address - Fax:760-326-8867
Practice Address - Street 1:9330 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:TRINITY
Practice Address - State:FL
Practice Address - Zip Code:34655-1808
Practice Address - Country:US
Practice Address - Phone:904-399-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ277702085R0202X
CAC517952085R0202X
FL1598352085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ914673Medicaid
CA00C517950Medicaid
NV100505339Medicaid
AZ101711Medicare ID - Type UnspecifiedGROUP
AZ914673Medicaid
AZ101712Medicare ID - Type UnspecifiedINDIVIDUAL
CAE11189Medicare UPIN
CA00C517950Medicare ID - Type UnspecifiedINDIVIDUAL