Provider Demographics
NPI:1679569651
Name:KELLY, EDWARD (DPM)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1760 E FLORENCE BLVD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85222-4764
Mailing Address - Country:US
Mailing Address - Phone:520-836-4868
Mailing Address - Fax:520-836-0759
Practice Address - Street 1:1760 E FLORENCE BLVD
Practice Address - Street 2:SUITE 160
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85222-4764
Practice Address - Country:US
Practice Address - Phone:520-836-4868
Practice Address - Fax:520-836-0759
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2008-12-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ0447213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0193380OtherBLUE CROSS BLUE SHIELD
AZ189705000OtherDEPARTMENT OF LABOR
AZ480027517OtherRAILROAD MEDICARE
AZ357774Medicaid
AZU61828Medicare UPIN
AZAZ0193380OtherBLUE CROSS BLUE SHIELD
AZ357774Medicaid
AZZDPM447Medicare PIN