Provider Demographics
NPI:1194810481
Name:WILEY, KELVIN JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:JAMES
Last Name:WILEY
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 1:1650 MARGARET ST
Mailing Address - Street 2:STE 302
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-3868
Mailing Address - Country:US
Mailing Address - Phone:803-718-6251
Mailing Address - Fax:
Practice Address - Street 1:4201 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1431
Practice Address - Country:US
Practice Address - Phone:803-718-6251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23431174400000X
FLME111390207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC234311Medicaid
SCH83436Medicare UPIN
SC234311Medicaid