Provider Demographics
NPI:1649210808
Name:KELTY, LISA ANN (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:KELTY
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:PO BOX 1203
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92018-1203
Mailing Address - Country:US
Mailing Address - Phone:904-343-4656
Mailing Address - Fax:
Practice Address - Street 1:H100 SANTA MARGERITA RD
Practice Address - Street 2:NAVAL HOSPITAL CAMP PENDLETON
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:904-343-4656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-1005-K207P00000X
CAC143642207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLVAD0000Medicare UPIN