Provider Demographics
NPI:1356377212
Name:ALEXANDER, KELLY L (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:ALEXANDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1199 BUSH ST STE 400
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94109-5975
Practice Address - Country:US
Practice Address - Phone:415-379-2890
Practice Address - Fax:415-349-6025
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC162278208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD313302800Medicaid
MDKG 65 ST / 616039-01OtherBC / BS OF MD
MDS186 / 0049OtherBLUECHOICE
MD313302800Medicaid
H65184Medicare UPIN