Provider Demographics
NPI:1457352189
Name:KELLEY, JUDITH ROBINSON (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:ROBINSON
Last Name:KELLEY
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 1:1080 EMELINE AVE
Mailing Address - Street 2:CLINIC ADMIN
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1966
Mailing Address - Country:US
Mailing Address - Phone:831-454-4100
Mailing Address - Fax:831-454-5001
Practice Address - Street 1:1080 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1966
Practice Address - Country:US
Practice Address - Phone:831-454-4100
Practice Address - Fax:831-454-5001
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG82177207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BK3367566OtherDEA
F89880Medicare UPIN
CA00G821770Medicare ID - Type Unspecified