Provider Demographics
NPI:1750763876
Name:RADFORD, KELLY REYNA (DO)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:REYNA
Last Name:RADFORD
Suffix:
Gender:F
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2202 CAROLINA PL
Practice Address - Street 2:STE 100
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086-8807
Practice Address - Country:US
Practice Address - Phone:980-487-2290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-00301207Q00000X
SCLL37631207Q00000X
SC37631207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1750763876Medicaid
SC376319Medicaid
SCSCB983J577OtherMEDICARE PIN
SCSCB9836084OtherMEDICARE PIN
SCSCB9836067OtherMEDICARE PIN