Provider Demographics
NPI:1316919442
Name:KELADA, YOUSSRY J (MD)
Entity type:Individual
Prefix:DR
First Name:YOUSSRY
Middle Name:J
Last Name:KELADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOE
Other - Middle Name:
Other - Last Name:KELADA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:680 SUNRISE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-4110
Mailing Address - Country:US
Mailing Address - Phone:916-786-4700
Mailing Address - Fax:916-786-3912
Practice Address - Street 1:680 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661
Practice Address - Country:US
Practice Address - Phone:916-786-4700
Practice Address - Fax:916-786-3912
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A370260207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942875159OtherTRICARE
CA00A370260OtherBLUESHIELD/BLUECROSS
CA00A370260Medicaid
CA080007629OtherGBA PALMETTO/RAILROAD
CA080007629OtherGBA PALMETTO/RAILROAD
CA00A370260Medicare ID - Type Unspecified