Provider Demographics
NPI:1538666748
Name:GOLD, KELLYANNE ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLYANNE
Middle Name:ROSE
Last Name:GOLD
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 1:7515 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-1949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20151 NORDHOFF ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-6215
Practice Address - Country:US
Practice Address - Phone:818-627-3050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-12
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA164250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine