Provider Demographics
NPI:1962498345
Name:KELLEY, DOUGLAS JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:JAMES
Last Name:KELLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S NEW YORK RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:GALLOWAY
Mailing Address - State:NJ
Mailing Address - Zip Code:08205-9650
Mailing Address - Country:US
Mailing Address - Phone:609-748-2288
Mailing Address - Fax:609-748-8866
Practice Address - Street 1:308 S NEW YORK RD UNIT D
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9650
Practice Address - Country:US
Practice Address - Phone:609-748-2288
Practice Address - Fax:609-748-8866
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-21
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00507000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU38629Medicare UPIN
NJ674209ZBLRMedicare PIN