Provider Demographics
NPI:1114211091
Name:WHITE, KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:WHITE
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 1:93 LA PATERA DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-8460
Mailing Address - Country:US
Mailing Address - Phone:818-584-4108
Mailing Address - Fax:
Practice Address - Street 1:93 LA PATERA DR
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-8460
Practice Address - Country:US
Practice Address - Phone:818-584-4108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09931600207L00000X
CAA156556207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology