Provider Demographics
NPI:1942299912
Name:KELLY, KEVIN M (MEDICAL DOCTOR)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:KELLY
Suffix:
Gender:M
Credentials:MEDICAL DOCTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-7089
Mailing Address - Country:US
Mailing Address - Phone:626-821-1411
Mailing Address - Fax:626-821-0406
Practice Address - Street 1:50 ALESSANDRO PL
Practice Address - Street 2:SUITE A30 & A40
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3149
Practice Address - Country:US
Practice Address - Phone:626-793-6141
Practice Address - Fax:626-796-0172
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG243302085B0100X, 2085R0202X, 2085N0904X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Not Answered2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G243300Medicaid
CA00G243300Medicaid
CAWG24330AMedicare ID - Type Unspecified