Provider Demographics
NPI:1306895941
Name:KELLY, ROY A JR (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:A
Last Name:KELLY
Suffix:JR
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 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:9001 SUMMA AVENUE
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809-3726
Practice Address - Country:US
Practice Address - Phone:225-761-5259
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA010587208800000X
LAMD.010587208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1336297Medicaid
MS05877708Medicaid
LA340007213OtherRAILROAD MEDICARE
LA340007213OtherRAILROAD MEDICARE
LA1336297Medicaid
LA525336629Medicare PIN