Provider Demographics
NPI:1336155381
Name:MCCANN, KELLY KATHLYN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:KATHLYN
Last Name:MCCANN
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 1:351 OLD NEWPORT BLVD # 218
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4120
Mailing Address - Country:US
Mailing Address - Phone:949-574-5800
Mailing Address - Fax:949-612-2725
Practice Address - Street 1:1831 ORANGE AVE STE C
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-2839
Practice Address - Country:US
Practice Address - Phone:949-574-5800
Practice Address - Fax:949-612-2725
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9492207R00000X
AZ30799208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORI12587Medicare UPIN