Provider Demographics
NPI:1346535267
Name:MA, KELLY (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:MA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 E CONCORD ST FL 8
Mailing Address - Street 2:DEPT OF OPHTHALMOLOGY
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-2335
Mailing Address - Country:US
Mailing Address - Phone:617-414-4020
Mailing Address - Fax:
Practice Address - Street 1:1040 NW 22ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3057
Practice Address - Country:US
Practice Address - Phone:503-413-8498
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD171281207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology