Provider Demographics
NPI:1841203130
Name:KELLEY, RANDALL GRANT (DO)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:GRANT
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:NAVAL HOSPITAL
Mailing Address - Street 2:ONE BOONE ROAD
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-1898
Mailing Address - Country:US
Mailing Address - Phone:360-475-4426
Mailing Address - Fax:360-475-4344
Practice Address - Street 1:NAVAL HOSPITAL
Practice Address - Street 2:ONE BOONE ROAD
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1898
Practice Address - Country:US
Practice Address - Phone:360-475-4426
Practice Address - Fax:360-475-4344
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003754207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine