Healthcare Provider Details

I. General information

NPI: 1477906915
Provider Name (Legal Business Name): JUSTIN KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 12/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

661 E ALTAMONTE DR STE 220
ALTAMONTE SPRINGS FL
32701-5102
US

IV. Provider business mailing address

661 E ALTAMONTE DR STE 220
ALTAMONTE SPRINGS FL
32701-5102
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-5191
  • Fax: 407-303-5193
Mailing address:
  • Phone: 407-303-5191
  • Fax: 407-303-5193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME134463
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTRN22550
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: