Provider Demographics
NPI:1902277940
Name:KELLY AHMED M.D., INC.
Entity Type:Organization
Organization Name:KELLY AHMED M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-955-7095
Mailing Address - Street 1:14285 AMARGOSA RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-9707
Mailing Address - Country:US
Mailing Address - Phone:760-955-7095
Mailing Address - Fax:760-951-1076
Practice Address - Street 1:14285 AMARGOSA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-9707
Practice Address - Country:US
Practice Address - Phone:760-955-7095
Practice Address - Fax:760-951-1076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-16
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51407207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA51407OtherMEDICAL LICEANSE