Healthcare Provider Details

I. General information

NPI: 1871528802
Provider Name (Legal Business Name): TIMOTHY KELLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 11/03/2023
Certification Date: 11/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SUPERIOR AVE STE 315
NEWPORT BEACH CA
92663-3667
US

IV. Provider business mailing address

PO BOX 2975
SUISUN CITY CA
94585-5975
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-3223
  • Fax: 949-645-3222
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberG78999
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: