Provider Demographics
NPI:1326206681
Name:KELLEY, KAL (MD)
Entity Type:Individual
Prefix:
First Name:KAL
Middle Name:
Last Name:KELLEY
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:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:CHEWELAH
Mailing Address - State:WA
Mailing Address - Zip Code:99109
Mailing Address - Country:US
Mailing Address - Phone:509-935-6001
Mailing Address - Fax:509-935-4196
Practice Address - Street 1:358 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-7005
Practice Address - Country:US
Practice Address - Phone:509-684-1440
Practice Address - Fax:509-684-2745
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD150135207Q00000X
WAMD60027802207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine