Provider Demographics
NPI:1811924764
Name:KELLY, KEVIN M JR
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:M
Last Name:KELLY
Suffix:JR
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:KEVIN
Other - Middle Name:MICHAEL
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12170
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2170
Mailing Address - Country:US
Mailing Address - Phone:877-818-6102
Mailing Address - Fax:
Practice Address - Street 1:5555 GROSSMONT CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3019
Practice Address - Country:US
Practice Address - Phone:619-644-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71711207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA71711Medicaid
CA00A717110Medicaid
CA00A717110Medicaid
CAWA71711DMedicare PIN
CAHA71711Medicare PIN
CAWA71711CMedicare PIN