Provider Demographics
NPI:1154811800
Name:KELLOCK, TRENTON TYLER (MD)
Entity type:Individual
Prefix:MR
First Name:TRENTON
Middle Name:TYLER
Last Name:KELLOCK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:WOMEN'S HOSPITAL DEPARTMENT OF RADIOLOGY
Mailing Address - Street 2:75 FRANCIS ST, ATTN DR TENTON KELLOCK
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115
Mailing Address - Country:US
Mailing Address - Phone:617-732-7537
Mailing Address - Fax:617-732-6336
Practice Address - Street 1:75 FRANCIS ST.
Practice Address - Street 2:MSK FELLOWSHIP, DEPT. OF RADIOLOGY, RA-3, BRIGHAM & WOM
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115
Practice Address - Country:US
Practice Address - Phone:617-732-6266
Practice Address - Fax:978-352-9015
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-17
Last Update Date:2019-01-15
Deactivation Date:2019-01-09
Deactivation Code:
Reactivation Date:2019-01-15
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program