Provider Demographics
NPI:1265598015
Name:KELLY, LESA A (MD)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:A
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 TRENOR DR
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10804-3719
Mailing Address - Country:US
Mailing Address - Phone:914-637-2663
Mailing Address - Fax:914-632-2016
Practice Address - Street 1:1296 NORTH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:NEW ROCHELLE
Practice Address - State:NY
Practice Address - Zip Code:10804-2603
Practice Address - Country:US
Practice Address - Phone:914-637-2663
Practice Address - Fax:914-632-2016
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1358881OtherMAGNACARE PROVIDER ID
NYP1844761OtherOXFORD ID
NYA400003316OtherMEDICARE PTAN
NY010191220NY01OtherEMPIRE GOV PAN PROVIDER I
NY134081364OtherTAX ID
NY2200529OtherGHI
NY2295900OtherAETNA PROVIDER ID
NY10U801Medicare ID - Type UnspecifiedPROVIDER ID