Healthcare Provider Details

I. General information

NPI: 1750567244
Provider Name (Legal Business Name): KELLY K MCCANN MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 02/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1831 ORANGE AVE STE C
COSTA MESA CA
92627-2839
US

IV. Provider business mailing address

1831 ORANGE AVE STE C
COSTA MESA CA
92627-2839
US

V. Phone/Fax

Practice location:
  • Phone: 949-574-5800
  • Fax: 949-612-2725
Mailing address:
  • Phone: 949-574-5800
  • Fax: 949-612-2725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA101853
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA101853
License Number StateCA

VIII. Authorized Official

Name: KELLY K MCCANN
Title or Position: MD
Credential: MD
Phone: 949-574-5800