Provider Demographics
NPI:1912080094
Name:KELLY, ELEANOR MARIE (MD)
Entity Type:Individual
Prefix:
First Name:ELEANOR
Middle Name:MARIE
Last Name:KELLY
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 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4800
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:241 IMPERIAL HWY
Practice Address - Street 2:SUITE 350
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-1055
Practice Address - Country:US
Practice Address - Phone:714-578-8669
Practice Address - Fax:714-578-8629
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA064544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH28231Medicare UPIN