Provider Demographics
NPI:1134159171
Name:KELLETT, ROBERT J (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:KELLETT
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 1:219-A NORTH MINE STREET
Mailing Address - Street 2:
Mailing Address - City:MCCORMICK
Mailing Address - State:SC
Mailing Address - Zip Code:29835
Mailing Address - Country:US
Mailing Address - Phone:864-852-3336
Mailing Address - Fax:864-852-3339
Practice Address - Street 1:810 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:LOUDON
Practice Address - State:TN
Practice Address - Zip Code:37774-1309
Practice Address - Country:US
Practice Address - Phone:865-657-9303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000038388207Q00000X
GA78348207Q00000X
ALMD.41971207Q00000X
SC29593207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I29645Medicare UPIN