Provider Demographics
NPI:1558383836
Name:KELLETT, CYRIL F (MD)
Entity type:Individual
Prefix:
First Name:CYRIL
Middle Name:F
Last Name:KELLETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3927 WARING RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4458
Mailing Address - Country:US
Mailing Address - Phone:760-758-1120
Mailing Address - Fax:760-758-7752
Practice Address - Street 1:3927 WARING RD
Practice Address - Street 2:SUITE A
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4458
Practice Address - Country:US
Practice Address - Phone:760-758-1120
Practice Address - Fax:760-758-7752
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG17806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40198Medicare UPIN