Provider Demographics
NPI:1356388060
Name:KELLY, MALCOLM H JR (OD)
Entity type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:H
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:49 S 2ND ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:PA
Practice Address - Zip Code:19363-1370
Practice Address - Country:US
Practice Address - Phone:610-932-9356
Practice Address - Fax:610-932-3097
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA091164OtherMEDICARE ID - GROUP MEDICARE NO.
PAOEG000335OtherPA STATE LICENSE NO.
PA5426540001OtherDMERC JURISDICTION A
PAU06849Medicare UPIN
PA091164OtherMEDICARE ID - GROUP MEDICARE NO.
PA5426540001Medicare NSC