Provider Demographics
NPI:1417018219
Name:DAVID M. KELLEY, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DAVID M. KELLEY, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-277-2255
Mailing Address - Street 1:PO BOX V
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-0150
Mailing Address - Country:US
Mailing Address - Phone:650-691-0611
Mailing Address - Fax:650-691-0614
Practice Address - Street 1:8950 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-3561
Practice Address - Country:US
Practice Address - Phone:310-277-2255
Practice Address - Fax:310-277-0625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59774207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW16897Medicare PIN