Provider Demographics
NPI:1164574141
Name:LONDON, KELLEY J (MD)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:J
Last Name:LONDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:900 N WESTMORELAND RD
Mailing Address - Street 2:SUITE #207
Mailing Address - City:LAKE FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60045-1674
Mailing Address - Country:US
Mailing Address - Phone:847-234-9110
Mailing Address - Fax:847-234-0900
Practice Address - Street 1:900 N WESTMORELAND RD
Practice Address - Street 2:SUITE #207
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-1674
Practice Address - Country:US
Practice Address - Phone:847-234-9110
Practice Address - Fax:847-234-0900
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL 54563Medicare PIN
ILG32588Medicare UPIN