Provider Demographics
NPI:1144678921
Name:KELLY, CALEB (MD)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2003 KOOTENAI HEALTH WAY
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-6051
Mailing Address - Country:US
Mailing Address - Phone:208-625-4595
Mailing Address - Fax:208-625-4596
Practice Address - Street 1:1919 LINCOLN WAY STE 415
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2527
Practice Address - Country:US
Practice Address - Phone:208-625-4595
Practice Address - Fax:208-625-4596
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-02
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-16777207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology