Provider Demographics
NPI:1770649071
Name:KELLY, PETER DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:DOUGLAS
Last Name:KELLY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EL CAMINO REAL FL 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3208
Mailing Address - Country:US
Mailing Address - Phone:650-742-3264
Mailing Address - Fax:
Practice Address - Street 1:1200 EL CAMINO REAL FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-3208
Practice Address - Country:US
Practice Address - Phone:650-742-3264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA846182085R0202X, 2085R0204X
PAMD4297172085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology