Provider Demographics
NPI:1902824295
Name:KELLY, JOHN JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:JR
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 1:24500 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2414
Mailing Address - Country:US
Mailing Address - Phone:248-353-1280
Mailing Address - Fax:248-353-6193
Practice Address - Street 1:24500 NORTHWESTERN HWY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2414
Practice Address - Country:US
Practice Address - Phone:248-353-1280
Practice Address - Fax:248-353-6193
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101006257174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1205209Medicaid
E31647Medicare UPIN