Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1942374731 |
---|---|
Provider Name | Mr. John J Kelley JR. |
First Address | Towson, MD 21204-2140 |
Second Address | Towson, MD 21204-2140 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/11/2006 |
Last Update Date | 28/03/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
52455501 | BC BS REGION (01) | MD |
Y391 | FED BC BS (01) | MD |