1043654007 NPI number — JASON KELTY D.P.M.

Table of content: JASON KELTY D.P.M. (NPI 1043654007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043654007 NPI number — JASON KELTY D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELTY
Provider First Name:
JASON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043654007
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3733 PARK EAST DR
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
BEACHWOOD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44122-4338
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
216-672-4330
Provider Business Mailing Address Fax Number:
866-571-4884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
116 EAST AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
TALLMADGE
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44278-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
216-245-1290
Provider Business Practice Location Address Fax Number:
866-571-4884
Provider Enumeration Date:
04/22/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  36003762 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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