Provider Demographics
NPI:1174871255
Name:KELLY, CATHERINE (DO)
Entity type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 MAPLE AVE
Mailing Address - Street 2:BOX 119
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-7500
Mailing Address - Country:US
Mailing Address - Phone:914-224-3884
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795
Practice Address - Country:US
Practice Address - Phone:631-376-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY279380207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine