Provider Demographics
NPI:1588624084
Name:KELLY, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8337 TELEGRAPH RD
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-4941
Mailing Address - Country:US
Mailing Address - Phone:562-776-3444
Mailing Address - Fax:562-776-3411
Practice Address - Street 1:8337 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-4909
Practice Address - Country:US
Practice Address - Phone:562-776-3444
Practice Address - Fax:562-776-3411
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39942174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G399420OtherMEDI-CAL
CA00G399420OtherBLUE SHIELD
CA00G399420OtherBLUE SHIELD