Provider Demographics
NPI:1639130255
Name:WHITT, KELLI GAMBILL (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:GAMBILL
Last Name:WHITT
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 1:176 OLD BRIDGE RD
Mailing Address - Street 2:DANVILLE
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-8804
Mailing Address - Country:US
Mailing Address - Phone:859-238-0265
Mailing Address - Fax:
Practice Address - Street 1:303 S 4TH ST
Practice Address - Street 2:DANVILLE
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2004
Practice Address - Country:US
Practice Address - Phone:859-238-0265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36424208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64023048Medicaid
KY00116002Medicare ID - Type UnspecifiedPRIMARY CARE MEDICARE NUM
KY0211405Medicare ID - Type Unspecified
KYH36006Medicare UPIN