Provider Demographics
NPI:1538202726
Name:MERVAT KELADA M D A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MERVAT KELADA M D A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVAT
Authorized Official - Middle Name:GAMIL
Authorized Official - Last Name:KELADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-355-4150
Mailing Address - Street 1:207 E BARIONI BLVD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-1619
Mailing Address - Country:US
Mailing Address - Phone:760-355-2999
Mailing Address - Fax:760-355-4150
Practice Address - Street 1:207 E BARIONI BLVD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-1619
Practice Address - Country:US
Practice Address - Phone:760-355-2999
Practice Address - Fax:760-355-4150
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE ANZA CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-15
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48353207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48353OtherMD LICENSE #
CA00A483532Medicaid
CA00A483531OtherINSURANCE
CA00A483532Medicaid
CA00A483532Medicaid