Provider Demographics
NPI:1417127317
Name:KELLEY, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KELLEY
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 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:SUITE 262
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:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-06
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60931082207RC0200X
CAG59774207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G597740Medicaid
TX215964201Medicaid
CAWG59774NMedicare PIN
CA00G597740Medicaid
TXTXB110201Medicare PIN
TX215964202Medicare PIN
TXTXB110204Medicare PIN