Healthcare Provider Details

I. General information

NPI: 1962568840
Provider Name (Legal Business Name): KELLY THOMAS WOYEWODZIC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KELLY THOMAS AZAR-WOYEWODZIC M.D.

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 12/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10323 SANTA MONICA BLVD. SUITE 101
LOS ANGELES CA
90025
US

IV. Provider business mailing address

10323 SANTA MONICA BLVD. SUITE 101
LOS ANGELES CA
90025
US

V. Phone/Fax

Practice location:
  • Phone: 310-499-1350
  • Fax: 310-360-0868
Mailing address:
  • Phone: 310-499-1350
  • Fax: 310-360-0868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number229504
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA92740
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number92740
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: