Provider Demographics
NPI:1821322710
Name:KELLY, PATRICK (ABOC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 W PATAPSCO AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-3400
Mailing Address - Country:US
Mailing Address - Phone:410-355-6900
Mailing Address - Fax:410-355-6910
Practice Address - Street 1:1490 W PATAPSCO AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-3400
Practice Address - Country:US
Practice Address - Phone:410-355-6900
Practice Address - Fax:410-355-6910
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2009-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD43480156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician