Provider Demographics
NPI:1386619526
Name:KELLY, ROBERT O (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:O
Last Name:KELLY
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:PO BOX 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:3931 MUNDY MILL RD.
Practice Address - Street 2:
Practice Address - City:OAKWOOD
Practice Address - State:GA
Practice Address - Zip Code:30566
Practice Address - Country:US
Practice Address - Phone:770-503-1481
Practice Address - Fax:770-503-1520
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA34384207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA034384OtherMED LIC NUMBER
GA11D0898435OtherCLIA
GA11D0898435OtherCLIA
GA11D0898435OtherCLIA
GABK0569395OtherDEA NUMBER