Provider Demographics
NPI:1942340625
Name:KELLEY PARK MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:KELLEY PARK MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:LINH
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-794-2088
Mailing Address - Street 1:749 STORY RD
Mailing Address - Street 2:SUITE 20
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-2600
Mailing Address - Country:US
Mailing Address - Phone:408-794-2088
Mailing Address - Fax:408-292-2179
Practice Address - Street 1:749 STORY RD
Practice Address - Street 2:SUITE 20
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-2600
Practice Address - Country:US
Practice Address - Phone:408-794-2088
Practice Address - Fax:408-292-2179
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7360261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX73600Medicaid
CA023997OtherVFC
CAH27272Medicare UPIN
CA020A73601Medicare ID - Type Unspecified