Provider Demographics
NPI:1477651222
Name:KELLY, KAREN (MD)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 X ST
Mailing Address - Street 2:SUITE 3016
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2229
Mailing Address - Country:US
Mailing Address - Phone:916-734-3771
Mailing Address - Fax:
Practice Address - Street 1:2279 45TH STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2229
Practice Address - Country:US
Practice Address - Phone:916-734-5959
Practice Address - Fax:916-703-5265
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-32107207RH0003X
CO27577207RX0202X
CAG88845207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS209037701Medicaid
CO01275775Medicaid
KS209037701Medicaid
CO01275775Medicaid