Provider Demographics
NPI:1558515254
Name:FOSTER, KELLY HOLLIDAY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:HOLLIDAY
Last Name:FOSTER
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 1:760 WESTWOOD PLZ # C8-222
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-5055
Mailing Address - Country:US
Mailing Address - Phone:310-206-3415
Mailing Address - Fax:
Practice Address - Street 1:760 WESTWOOD PLZ
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-5055
Practice Address - Country:US
Practice Address - Phone:310-825-6301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1076892084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A1076890Medicaid
CADX787YMedicare PIN