Provider Demographics
NPI:1346205663
Name:KELLY, RICHARD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:23625 HOLMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:831-624-5311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80029207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G800290Medicaid
NV100510377Medicaid
CAG21766Medicare UPIN
CA00G800290Medicaid
CA00G800293Medicare PIN
NV100510377Medicaid