Healthcare Provider Details

I. General information

NPI: 1932186202
Provider Name (Legal Business Name): KELLEY STODDARD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14546 OLD SAINT AUGUSTINE RD STE 305&311
JACKSONVILLE FL
32258-5468
US

IV. Provider business mailing address

PO BOX 25317
TAMPA FL
33622-5317
US

V. Phone/Fax

Practice location:
  • Phone: 904-260-2255
  • Fax: 904-260-2251
Mailing address:
  • Phone: 813-286-0033
  • Fax: 813-282-1806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberWV22001
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME105067
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: