Provider Demographics
NPI:1992886451
Name:KELLY, DANIEL L (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1775
Mailing Address - Fax:704-384-1776
Practice Address - Street 1:5717 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-1634
Practice Address - Country:US
Practice Address - Phone:704-563-2150
Practice Address - Fax:704-563-2153
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37870207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912946Medicaid
NCNCB234AMedicare PIN
NCNCB234FMedicare PIN
NCNCB234GMedicare PIN
NCNCB234CMedicare PIN
NCNCB234EMedicare PIN
NC8912946Medicaid
NCNCB234DMedicare PIN
NC2151106EMedicare PIN
NCNCB234BMedicare PIN