Provider Demographics
NPI:1770604043
Name:KELLY, KEITH STEFON (MD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:STEFON
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:11701 LIVINGSTON RD STE 308
Mailing Address - Street 2:
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:MD
Mailing Address - Zip Code:20744-5146
Mailing Address - Country:US
Mailing Address - Phone:301-632-6900
Mailing Address - Fax:301-632-6901
Practice Address - Street 1:11701 LIVINGSTON RD STE 308
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5146
Practice Address - Country:US
Practice Address - Phone:301-292-6140
Practice Address - Fax:240-559-0895
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0054969207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD156002600Medicaid
MD402RMedicare PIN
MD156002600Medicaid