Provider Demographics
NPI:1255845657
Name:KELLY BICKLE MD INC
Entity Type:Organization
Organization Name:KELLY BICKLE MD INC
Other - Org Name:KELLY BICKLE, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:BICKLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-878-4590
Mailing Address - Street 1:1244 7TH ST STE 204
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-1648
Mailing Address - Country:US
Mailing Address - Phone:310-878-4590
Mailing Address - Fax:424-214-3301
Practice Address - Street 1:1244 7TH ST STE 204
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-1648
Practice Address - Country:US
Practice Address - Phone:310-878-4590
Practice Address - Fax:424-214-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-21
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95166207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty