Provider Demographics
NPI:1184668741
Name:DEWITT, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DEWITT
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:DEPT 338
Mailing Address - Street 2:PO BOX 509015
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92150-9015
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5555 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-644-4500
Practice Address - Fax:619-644-4547
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74873174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A748730Medicaid
CAA74873OtherMEDICAL LICENSE
CA00A748730Medicaid
CAWA74873CMedicare PIN
CAWA74873BMedicare PIN
CAI15586Medicare UPIN
CAWA74873EMedicare PIN
CAWA74873DMedicare PIN