Healthcare Provider Details

I. General information

NPI: 1174150163
Provider Name (Legal Business Name): JOHN JOSEPH KELLY IV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10155 DOWDEN RD STE 301
ORLANDO FL
32832-5227
US

IV. Provider business mailing address

10155 DOWDEN RD STE 301
ORLANDO FL
32832-5227
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-5851
  • Fax: 407-569-1701
Mailing address:
  • Phone: 321-843-5851
  • Fax: 407-569-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number79276
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberME181916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: