Provider Demographics
NPI:1255333035
Name:KELADA, MERVAT G (MD)
Entity Type:Individual
Prefix:
First Name:MERVAT
Middle Name:G
Last Name:KELADA
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 1:1001 BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231
Mailing Address - Country:US
Mailing Address - Phone:760-768-5055
Mailing Address - Fax:760-768-5037
Practice Address - Street 1:1001 BLAIR AVE
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231
Practice Address - Country:US
Practice Address - Phone:760-768-5055
Practice Address - Fax:760-768-5037
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA032437OtherVFC IDENTIFIER
AZ28248OtherARIZONA LICENSE NUMBER
CAA48353OtherLICENSE NUMBER
CARHM53866FMedicaid
MI13070OtherMISSISSIPPI LICENSE NUMBE
FLME 62257OtherFLORIDA LICENSE NUMBER
CA00A483531OtherINSURANCE
CA330742343OtherE.I.N. NUMBER
CA05D0906507OtherCLIA ID NUMBER
CA05D0906507OtherCLIA ID NUMBER
CA330742343OtherE.I.N. NUMBER
CABK7190034OtherDEA NUMBER
CAA48353OtherLICENSE NUMBER