MEDICARE: KELLEY PARK MEDICAL CLINIC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	20A7360	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	023997	OTHER	CA	VFC

General Provider Information

NPI Number	:	1942340625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLEY PARK MEDICAL CLINIC, INC

Provider Business Mailing Address
First Line	:	749 STORY RD
Second Line	:	SUITE 20
City	:	SAN JOSE
State	:	CA
Zip	:	95122-2600
Country	:	US
Telephone Number	:	408-794-2088
Fax Number	:	408-292-2179

Provider Business Practice Location Address
First Line	:	749 STORY RD
Second Line	:	SUITE 20
City	:	SAN JOSE
State	:	CA
Zip	:	95122-2600
Country	:	US
Telephone Number	:	408-794-2088
Fax Number	:	408-292-2179

Authorized Official
Title or Position	:	DR
Name	:	DR. PETER LINH NGUYEN
Credential	:	D.O.
Telephone Number	:	408-794-2088

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/15/2007

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