Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 36003762 | OH |
Y | 222Z00000X | Podiatrist | 36003762 | OH |
NPI | 1043654007 |
---|---|
Provider Name | Jason Kelty |
First Address | Beachwood, OH 44122-4338 |
Second Address | Tallmadge, OH 44278-2300 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2013 |
Last Update Date | 07/07/2016 |