Provider Demographics
NPI:1205256187
Name:KELLEY, JUSTIN (DO)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 SPIVEY CAMP RD
Mailing Address - Street 2:
Mailing Address - City:KINSTON
Mailing Address - State:AL
Mailing Address - Zip Code:36453-7030
Mailing Address - Country:US
Mailing Address - Phone:334-399-9555
Mailing Address - Fax:
Practice Address - Street 1:1401 BONE CREEK DR
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-7267
Practice Address - Country:US
Practice Address - Phone:419-625-4900
Practice Address - Fax:419-627-9768
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-18
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.014089207XX0801X, 207X00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381932Medicaid
OH34.014089OtherLICENSE