Healthcare Provider Details

I. General information

NPI: 1407266414
Provider Name (Legal Business Name): KELLI ODA D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2014
Last Update Date: 10/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE ATTN: MEDICAL STAFF SERVICES
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

12635 EL CAMINO REAL APT 4109
SAN DIEGO CA
92130-5009
US

V. Phone/Fax

Practice location:
  • Phone: 760-719-3621
  • Fax:
Mailing address:
  • Phone: 937-416-2108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: