Provider Demographics
NPI:1306108428
Name:KELLEY, DOUGLAS JOHN (DO)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:JOHN
Last Name:KELLEY
Suffix:
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 1:8380 CADILLAC CIR
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-2257
Mailing Address - Country:US
Mailing Address - Phone:734-818-7673
Mailing Address - Fax:
Practice Address - Street 1:8380 CADILLAC CIR
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2257
Practice Address - Country:US
Practice Address - Phone:734-818-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101020104390200000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program