MEDICARE: DR. KELLY WHITE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	A156556	CA

General Provider Information

NPI Number	:	1114211091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY WHITE M.D.

Provider Business Mailing Address
First Line	:	411 LOMBARD ST STE A
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93030-5145
Country	:	US
Telephone Number	:	818-584-4108
Fax Number	:

Provider Business Practice Location Address
First Line	:	411 LOMBARD ST STE A
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93030-5145
Country	:	US
Telephone Number	:	818-584-4108
Fax Number	:	805-603-4913

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	05/29/2026

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