Provider Demographics
NPI:1154397164
Name:KELTY, RICHARD H (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:H
Last Name:KELTY
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 1:2190 LYNN RD
Mailing Address - Street 2:STE 220
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:805-495-8050
Mailing Address - Fax:805-496-2160
Practice Address - Street 1:215 W JANSS RD
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-373-8582
Practice Address - Fax:805-373-6865
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39396207ZP0102X
NM84203207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG393960Medicaid
CAOOG393960Medicaid
A92078Medicare UPIN