Provider Demographics
NPI:1801962568
Name:BEATTY, KELLY D (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:D
Last Name:BEATTY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:D
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2165 EAST STREET
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520
Mailing Address - Country:US
Mailing Address - Phone:925-827-9195
Mailing Address - Fax:925-827-9278
Practice Address - Street 1:2165 EAST STREET
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:925-827-9195
Practice Address - Fax:925-827-9278
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG065709208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
E54097Medicare UPIN