Provider Demographics
NPI:1932100153
Name:GEOGHAN, KELLY L (DPM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:GEOGHAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 YORK ROAD
Mailing Address - Street 2:SUITE 504
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-6097
Mailing Address - Country:US
Mailing Address - Phone:410-753-4422
Mailing Address - Fax:410-753-4660
Practice Address - Street 1:1447 YORK ROAD
Practice Address - Street 2:SUITE 504
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-6097
Practice Address - Country:US
Practice Address - Phone:410-753-4422
Practice Address - Fax:410-753-4660
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD01285213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD6614180001OtherMEDICARE DMEPOS
MDCDJ4KL 758639-07OtherCAREFIRST
MDCDJ4KL 758639-06OtherCAREFIRST
DCY410-0001OtherCAREFIRST
MDCDJ4KL 758639-07OtherCAREFIRST