Provider Demographics
NPI:1497974125
Name:TRAVER-SELLING, KELLY DESELMS (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DESELMS
Last Name:TRAVER-SELLING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:DESELMS
Other - Last Name:TRAVER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:340 WILLOWBROOK DR
Mailing Address - Street 2:
Mailing Address - City:PORTOLA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94028-7842
Mailing Address - Country:US
Mailing Address - Phone:650-851-8758
Mailing Address - Fax:650-851-2258
Practice Address - Street 1:1600 AMPHITHEATRE PKWY
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1351
Practice Address - Country:US
Practice Address - Phone:650-253-0890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69021208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice