Provider Demographics
NPI:1265540686
Name:KELLY, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:382 W PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-5552
Mailing Address - Country:US
Mailing Address - Phone:973-338-1900
Mailing Address - Fax:973-761-0112
Practice Address - Street 1:382 W PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5552
Practice Address - Country:US
Practice Address - Phone:973-338-1900
Practice Address - Fax:973-761-0112
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA51866207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1753606Medicaid
NJ1753606Medicaid
NJ143251Medicare ID - Type Unspecified