Individual
DR. MALCOLM H. KELLY JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
Contact information
Practice address
49 S 2ND ST, OXFORD, PA 19363-1370
(610) 932-9356
(610) 932-3097
Mailing address
1950 OLD GALLOWS RD STE 520, VIENNA, VA 22182-3970
(703) 847-8899
(571) 223-6780
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
OEG000335
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
091164
MEDICARE ID - GROUP MEDICARE NO.
PA
01
—
5426540001
DMERC JURISDICTION A
PA
01
—
OEG000335
PA STATE LICENSE NO.
PA
Enumeration date
06/01/2006
Last updated
06/22/2021
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