Basic Information
| Provider Information | |||||||||
| NPI: | 1356388060 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | MALCOLM | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 OLD GALLOWS RD STE 520 | ||||||||
| Address2: | |||||||||
| City: | VIENNA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221823970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038478899 | ||||||||
| FaxNumber: | 5712236780 | ||||||||
| Practice Location | |||||||||
| Address1: | 49 S 2ND ST | ||||||||
| Address2: | |||||||||
| City: | OXFORD | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193631370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6109329356 | ||||||||
| FaxNumber: | 6109323097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OEG000335 | PA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 091164 | 01 | PA | MEDICARE ID - GROUP MEDICARE NO. | OTHER | OEG000335 | 01 | PA | PA STATE LICENSE NO. | OTHER | 5426540001 | 01 | PA | DMERC JURISDICTION A | OTHER |