Provider Demographics
NPI:1922004191
Name:KELLY, JAMES REGINALD (MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:REGINALD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
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Mailing Address - Street 1:1301 FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2325
Mailing Address - Country:US
Mailing Address - Phone:919-956-4508
Mailing Address - Fax:
Practice Address - Street 1:DUMC 3022
Practice Address - Street 2:WALLACE CLINIC
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-660-6746
Practice Address - Fax:919-681-4849
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20735207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948207Medicaid
NCC84876Medicare UPIN
NC8948207Medicaid