Basic Information
| Provider Information | |||||||||
| NPI: | 1003200171 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | |||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2050 S BLOSSER RD | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934587310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053618028 | ||||||||
| FaxNumber: | 8053618097 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 W CENTRAL AVE STE 201 | ||||||||
| Address2: | |||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934362807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057371169 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 08/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | 156668 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.