Provider Demographics
NPI:1770548265
Name:KELLY, DANIEL JOSEPH (MD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:JOSEPH
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 1:405 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2607
Mailing Address - Country:US
Mailing Address - Phone:541-298-5144
Mailing Address - Fax:541-298-5224
Practice Address - Street 1:405 E 7TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2607
Practice Address - Country:US
Practice Address - Phone:541-298-5144
Practice Address - Fax:541-298-5224
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD12291207W00000X
WAMD00022665207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR267104Medicaid
WA1257104OtherWASH WELF
WA1257104OtherWASH WELF
AK1597927OtherDEA
WA1257104OtherWASH WELF