Healthcare Provider Details

I. General information

NPI: 1174687560
Provider Name (Legal Business Name): FREDERICK KELLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 07/13/2023
Certification Date: 07/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N 10TH ST STE 3
SANTA PAULA CA
93060-1348
US

IV. Provider business mailing address

800 S VICTORIA AVE # L4640
VENTURA CA
93009-3099
US

V. Phone/Fax

Practice location:
  • Phone: 805-525-0215
  • Fax: 805-525-8031
Mailing address:
  • Phone: 805-525-0215
  • Fax: 805-525-8031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG71281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: