Provider Demographics
NPI:1477531481
Name:FORDYCE, KELLY ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ELIZABETH
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1671
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-6000
Practice Address - Fax:949-364-3213
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73294207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFA254ZMedicare PIN
CAWA73294CMedicare PIN
CAFA254YMedicare PIN
CAH70869Medicare UPIN