Provider Demographics
NPI:1700991320
Name:KELTY, GERALD A (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:A
Last Name:KELTY
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5693 YMCA PARK DR W
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46835-3280
Practice Address - Country:US
Practice Address - Phone:260-469-6603
Practice Address - Fax:260-486-6123
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044159A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000595579OtherANTHEM
IN200009310Medicaid
INPOO465467OtherRAILROAD MEDICARE UPIN
INF85982Medicare UPIN
IN055250UMedicare ID - Type Unspecified
IN259060KMedicare PIN
IN200009310Medicaid
INPOO465467OtherRAILROAD MEDICARE UPIN