Provider Demographics
NPI:1780671081
Name:KELLEY, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:15 VREELAND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01028-1631
Mailing Address - Country:US
Mailing Address - Phone:413-787-2555
Mailing Address - Fax:413-787-9992
Practice Address - Street 1:15 VREELAND AVE
Practice Address - Street 2:
Practice Address - City:EAST LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01028-1631
Practice Address - Country:US
Practice Address - Phone:413-787-2555
Practice Address - Fax:413-787-9992
Is Sole Proprietor?:No
Enumeration Date:2005-10-02
Last Update Date:2011-12-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA803122080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3130240Medicaid