Provider Demographics
NPI:1043960404
Name:KELLEY, DEVON (MD)
Entity type:Individual
Prefix:
First Name:DEVON
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 ARCH ST APT 410
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1534
Mailing Address - Country:US
Mailing Address - Phone:510-846-4843
Mailing Address - Fax:
Practice Address - Street 1:675 HOES LN W
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-8021
Practice Address - Country:US
Practice Address - Phone:732-235-7673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-28
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PA486586208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program