Provider Demographics
NPI:1972513299
Name:KELLY, VICTORIA CALVINA (MD)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:CALVINA
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4707 CABRIOLET LN.
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:567-455-5432
Mailing Address - Fax:567-316-6444
Practice Address - Street 1:3125 TRANSVERSE DR.
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43614-5811
Practice Address - Country:US
Practice Address - Phone:419-383-5695
Practice Address - Fax:419-383-3032
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350865122084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2854915Medicaid