Healthcare Provider Details

I. General information

NPI: 1700049186
Provider Name (Legal Business Name): LAWRENCE F.X. KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2008
Last Update Date: 07/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11445 SUNSET HILLS RD
RESTON VA
20190-5276
US

IV. Provider business mailing address

223 FALCON RIDGE RD
GREAT FALLS VA
22066-3518
US

V. Phone/Fax

Practice location:
  • Phone: 703-709-1600
  • Fax:
Mailing address:
  • Phone: 703-759-5737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101020841
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: