Provider Demographics
NPI:1871528802
Name:KELLEY, TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2975
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-5975
Mailing Address - Country:US
Mailing Address - Phone:657-241-3600
Mailing Address - Fax:657-241-7708
Practice Address - Street 1:520 SUPERIOR AVE STE 315
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3667
Practice Address - Country:US
Practice Address - Phone:949-645-3223
Practice Address - Fax:949-645-3222
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78999207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G789990Medicaid
CA00G789990Medicaid
CAF19116Medicare UPIN