Provider Demographics
NPI:1255582706
Name:YOUSSRY JOE Y KELADA, MD
Entity type:Organization
Organization Name:YOUSSRY JOE Y KELADA, MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:YOUSSRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KELADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-786-4700
Mailing Address - Street 1:406 SUNRISE AVE
Mailing Address - Street 2:#250
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4106
Mailing Address - Country:US
Mailing Address - Phone:916-786-4700
Mailing Address - Fax:916-786-3912
Practice Address - Street 1:406 SUNRISE AVE
Practice Address - Street 2:#250
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4106
Practice Address - Country:US
Practice Address - Phone:916-786-4700
Practice Address - Fax:916-786-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-02
Last Update Date:2009-10-23
Deactivation Date:2009-08-05
Deactivation Code:
Reactivation Date:2009-10-23
Provider Licenses
StateLicense IDTaxonomies
CAA370260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28262Medicare UPIN