Provider Demographics
NPI:1417480831
Name:KELLY, DANIEL H (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:H
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:877-348-1281
Mailing Address - Fax:901-227-3206
Practice Address - Street 1:501 MARSHALL ST STE 104
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-1663
Practice Address - Country:US
Practice Address - Phone:601-969-6404
Practice Address - Fax:601-973-4541
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2024-06-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS27519207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease