Basic Information
| Provider Information | |||||||||
| NPI: | 1043654007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELTY | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3733 PARK EAST DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | BEACHWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441224338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2166724330 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 EAST AVE | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | TALLMADGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442782300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2162451290 | ||||||||
| FaxNumber: | 8665714884 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2013 | ||||||||
| LastUpdateDate: | 07/07/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 36003762 | OH | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.