Provider Demographics
NPI:1225405962
Name:MERVAT KELADA M.D. A MEDICAL CORP
Entity Type:Organization
Organization Name:MERVAT KELADA M.D. A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVAT
Authorized Official - Middle Name:GAMIL
Authorized Official - Last Name:KELADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-562-6633
Mailing Address - Street 1:1001 BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2308
Mailing Address - Country:US
Mailing Address - Phone:760-768-5055
Mailing Address - Fax:760-768-5037
Practice Address - Street 1:207 E BARIONI BLVD STE A
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-1620
Practice Address - Country:US
Practice Address - Phone:760-355-2999
Practice Address - Fax:760-355-4150
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48353261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA553866Medicare PIN