Provider Demographics
NPI:1942374731
Name:KELLEY, JOHN J JR (BCO)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:KELLEY
Suffix:JR
Gender:M
Credentials:BCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1107 KENILWORTH DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2140
Mailing Address - Country:US
Mailing Address - Phone:410-828-5628
Mailing Address - Fax:419-828-5629
Practice Address - Street 1:1107 KENILWORTH DR
Practice Address - Street 2:SUITE 310
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-2140
Practice Address - Country:US
Practice Address - Phone:410-828-5628
Practice Address - Fax:419-828-5629
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDY391OtherFED BC BS
MD52455501OtherBC BS REGION
MD0184240003Medicare NSC