Healthcare Provider Details

I. General information

NPI: 1184668741
Provider Name (Legal Business Name): KELLY DEWITT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 02/18/2026
Certification Date: 02/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

PO BOX 509015 DEPT 338
SAN DIEGO CA
92150-9015
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4500
  • Fax: 619-740-8499
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA74873
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: