Healthcare Provider Details

I. General information

NPI: 1346205663
Provider Name (Legal Business Name): RICHARD J KELLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23625 HOLMAN HIGHWAY
MONTEREY CA
93940
US

IV. Provider business mailing address

PO BOX 7096
STOCKTON CA
95267-0096
US

V. Phone/Fax

Practice location:
  • Phone: 831-624-5311
  • Fax:
Mailing address:
  • Phone: 209-956-7725
  • Fax: 209-956-7733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG80029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: