Provider Demographics
NPI:1932137304
Name:COFFEY, KELLY P (DO)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:P
Last Name:COFFEY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:471 SIPPLE ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-8641
Mailing Address - Country:US
Mailing Address - Phone:310-422-1560
Mailing Address - Fax:
Practice Address - Street 1:471 SIPPLE ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-8641
Practice Address - Country:US
Practice Address - Phone:310-422-1560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012843207X00000X
CA20A19126207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2000000002774OtherPHYSICIANS HEALTH PLAN
MI4902586Medicaid
MI0C31365OtherBCBS
MIP26020007Medicare PIN
MI0C31365OtherBCBS