Provider Demographics
NPI:1215924253
Name:KELLEY, MARTY J (DPM)
Entity type:Individual
Prefix:DR
First Name:MARTY
Middle Name:J
Last Name:KELLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2916 HAMILTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-2429
Mailing Address - Country:US
Mailing Address - Phone:712-255-1621
Mailing Address - Fax:712-255-1389
Practice Address - Street 1:2916 HAMILTON BLVD
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-2429
Practice Address - Country:US
Practice Address - Phone:712-255-1621
Practice Address - Fax:712-255-1389
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00763213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0435834Medicaid
IA0289124Medicaid
NE10025293700Medicaid
IAU94972Medicare UPIN
SD41795Medicare ID - Type UnspecifiedINDIVIDUAL #
IAI9441Medicare ID - Type UnspecifiedINDIVIDUAL #
IA0435834Medicaid
IAI7290Medicare ID - Type UnspecifiedGROUP #
IA0289124Medicaid
8HC677Medicare PIN
SDS8671Medicare ID - Type UnspecifiedGROUP #