Provider Demographics
NPI:1093889263
Name:KELLY, MARK JOSEPH (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:KELLY
Suffix:
Gender:M
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:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-396-8930
Mailing Address - Fax:239-396-8932
Practice Address - Street 1:8925 COLONIAL CENTER DR STE 2001
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7813
Practice Address - Country:US
Practice Address - Phone:239-396-8930
Practice Address - Fax:239-396-8932
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2025-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55252208800000X
FLME157212208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1598827826OtherINCORPORATION NPI
FL120219800Medicaid
CAG55252Medicare PIN