Provider Demographics
NPI:1356569263
Name:KELLY, THOMAS LAWRENCE JR (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LAWRENCE
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 4637
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-4637
Mailing Address - Country:US
Mailing Address - Phone:970-926-9586
Mailing Address - Fax:970-926-9587
Practice Address - Street 1:1140 EDWARDS VILLAGE BLVD.
Practice Address - Street 2:EDWARDS VILLAGE II, BLDG. B
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632
Practice Address - Country:US
Practice Address - Phone:970-926-7926
Practice Address - Fax:970-926-9587
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
CO39381207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
E16704Medicare UPIN
801248Medicare ID - Type Unspecified