Provider Demographics
NPI:1295784130
Name:BOYATT, KELLY ELIZABETH (MD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:BOYATT
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 1:225 EAST SECOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4249
Mailing Address - Country:US
Mailing Address - Phone:760-291-6700
Mailing Address - Fax:760-737-7324
Practice Address - Street 1:31795 RANCHO CALIFORNIA RD STE B-700
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-2993
Practice Address - Country:US
Practice Address - Phone:760-291-6700
Practice Address - Fax:951-294-9039
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FU294ZOtherMEDICARE PTAN
FU294ZOtherMEDICARE PTAN
CA00A809600Medicare PIN
CAI18544Medicare UPIN