Provider Demographics
NPI:1306857982
Name:KELLY, DANIEL F (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:F
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1328 22ND ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2032
Mailing Address - Country:US
Mailing Address - Phone:310-202-6204
Mailing Address - Fax:
Practice Address - Street 1:1328 22ND ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2032
Practice Address - Country:US
Practice Address - Phone:310-202-6204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77318207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773180Medicaid
CAWG77318IMedicare PIN
CAF66472Medicare UPIN
CA00G773180Medicaid