Provider Demographics
NPI:1134310659
Name:KELLA, KISHAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:KISHAN
Middle Name:L
Last Name:KELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:625 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4340
Mailing Address - Country:US
Mailing Address - Phone:989-752-6116
Mailing Address - Fax:989-752-0074
Practice Address - Street 1:625 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4340
Practice Address - Country:US
Practice Address - Phone:989-752-6116
Practice Address - Fax:989-752-0074
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIKK046739207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4600834Medicaid
B45595Medicare UPIN
MI4600834Medicaid