Provider Demographics
NPI:1407013246
Name:DZIALO, KELLY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ANN
Last Name:DZIALO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1233 LOCUST ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5453
Mailing Address - Country:US
Mailing Address - Phone:215-545-8188
Mailing Address - Fax:215-545-8446
Practice Address - Street 1:1233 LOCUST ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5453
Practice Address - Country:US
Practice Address - Phone:215-545-8188
Practice Address - Fax:215-545-8446
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08740500208000000X
PAMD452160208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
077356 SK3Medicare UPIN