Provider Demographics
NPI:1306808647
Name:KELLY, CAROL B (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:B
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:668 ALLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7406
Mailing Address - Country:US
Mailing Address - Phone:718-652-1151
Mailing Address - Fax:718-652-5799
Practice Address - Street 1:668 ALLERTON AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-7406
Practice Address - Country:US
Practice Address - Phone:718-652-1151
Practice Address - Fax:718-652-5799
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY149181207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00705986Medicaid
NYE61165Medicare UPIN
NY00705986Medicaid