Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 018829 | ME |
NPI | 1013030378 |
---|---|
Provider Name | Kurt Kelley |
First Address | Brunswick, ME 04011-1514 |
Second Address | Brunswick, ME 04011-1514 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/04/2007 |
Last Update Date | 11/12/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
FK2667446 | DEA (01) | ME |
MD18829 | LICENSE (01) | ME |