Provider Demographics
NPI:1871501999
Name:BOMER, KELLY VANDERBILT (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:VANDERBILT
Last Name:BOMER
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 1:9155 E BELL RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85260-1521
Mailing Address - Country:US
Mailing Address - Phone:480-889-8870
Mailing Address - Fax:480-889-8871
Practice Address - Street 1:9155 E BELL RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85260-1521
Practice Address - Country:US
Practice Address - Phone:480-889-8870
Practice Address - Fax:480-889-8871
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30302207YS0123X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ109032Medicare PIN
AZI51059Medicare UPIN