Provider Demographics
NPI:1548930803
Name:DEAN M KELAITA M D MEDICAL
Entity type:Organization
Organization Name:DEAN M KELAITA M D MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KELAITA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-483-4760
Mailing Address - Street 1:PO BOX 30
Mailing Address - Street 2:
Mailing Address - City:MOKELUMNE HILL
Mailing Address - State:CA
Mailing Address - Zip Code:95245-0030
Mailing Address - Country:US
Mailing Address - Phone:209-483-4760
Mailing Address - Fax:
Practice Address - Street 1:900 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-483-4760
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty