Individual
DR. MALCOLM H. KELLY JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
OD
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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