Provider Demographics
NPI:1982618690
Name:KELLY, JOHN B JR (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:B
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 LEE ST E STE 201
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1864
Mailing Address - Country:US
Mailing Address - Phone:304-342-8513
Mailing Address - Fax:304-342-8147
Practice Address - Street 1:1220 LEE ST E STE 201
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1864
Practice Address - Country:US
Practice Address - Phone:304-342-8513
Practice Address - Fax:304-342-8147
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV774207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0056727000Medicaid
WVD71721Medicare UPIN
0530836Medicare PIN