Provider Demographics
NPI:1023070257
Name:DEBOER, KELLY L (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:DEBOER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1020 LAKE SUMTER LNDG
Mailing Address - Street 2:
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-2699
Mailing Address - Country:US
Mailing Address - Phone:352-674-8905
Mailing Address - Fax:352-674-8901
Practice Address - Street 1:2910 BROWNWOOD BLVD
Practice Address - Street 2:
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32163-2032
Practice Address - Country:US
Practice Address - Phone:352-674-1790
Practice Address - Fax:352-674-8990
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME154684207Q00000X
NE20671207Q00000X
IL036129069207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO6244220Medicaid
IL819300036Medicare PIN
COI65852Medicare UPIN
CO6244220Medicaid