Provider Demographics
NPI:1356306575
Name:KELLY, IMELDA C (MD)
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:C
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:IMELDA
Other - Middle Name:ELORIAGA
Other - Last Name:CALUBAQUIB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-408-7010
Mailing Address - Fax:
Practice Address - Street 1:1350 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2011
Practice Address - Country:US
Practice Address - Phone:503-408-7010
Practice Address - Fax:503-408-7035
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD23862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR286671Medicaid
G67468Medicare UPIN
ORR113888Medicare PIN