Provider Demographics
NPI:1922089556
Name:KELLY, DANIEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:701 RANDOLPH ST STE 120
Mailing Address - Street 2:
Mailing Address - City:RADFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24141-3047
Mailing Address - Country:US
Mailing Address - Phone:540-731-3200
Mailing Address - Fax:540-639-1048
Practice Address - Street 1:701 RANDOLPH ST STE 120
Practice Address - Street 2:
Practice Address - City:RADFORD
Practice Address - State:VA
Practice Address - Zip Code:24141-3047
Practice Address - Country:US
Practice Address - Phone:540-731-3200
Practice Address - Fax:540-639-1048
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-08-12
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA0101-039704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010299268Medicaid
VA5623502Medicaid
080005647Medicare PIN
010696C07Medicare PIN
VAB09495Medicare UPIN
VA010696C07Medicare PIN