Provider Demographics
NPI:1083606776
Name:PFEIFER, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PFEIFER
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 1:1301 SOUTHPOINT BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6858
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7570
Practice Address - Street 1:1301 SOUTHPOINT BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-6858
Practice Address - Country:US
Practice Address - Phone:707-559-7500
Practice Address - Fax:707-559-7570
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP70696FMedicaid
CAZZZ18742ZOtherISSUER MEDICARE
CAFHC70696FMedicaid
CAA66577OtherLICENSE
CABCP70696FMedicaid
CABCP70696FMedicaid
CA551879Medicare Oscar/Certification