Basic Information
| Provider Information | |||||||||
| NPI: | 1689813560 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GEORGE KEITH LLEWELLYN, MD, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALOE DERMATOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1722 STATE ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931012526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058844900 | ||||||||
| FaxNumber: | 8054568118 | ||||||||
| Practice Location | |||||||||
| Address1: | 1722 STATE ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931012526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8058844900 | ||||||||
| FaxNumber: | 8054568118 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2009 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LLEWELLYN | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | KEITH | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8058844900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | N | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty | 207N00000X | A80609 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | ZZZ55678Y | 01 | CA | BLUE SHIELD | OTHER |