Healthcare Provider Details

I. General information

NPI: 1932100153
Provider Name (Legal Business Name): KELLY L. GEOGHAN D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 YORK ROAD SUITE 504
LUTHERVILLE MD
21093-6097
US

IV. Provider business mailing address

1447 YORK ROAD SUITE 504
LUTHERVILLE MD
21093-6097
US

V. Phone/Fax

Practice location:
  • Phone: 410-753-4422
  • Fax: 410-753-4660
Mailing address:
  • Phone: 410-753-4422
  • Fax: 410-753-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number01285
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: