Provider Demographics
NPI:1386617942
Name:KIELTY, MICHELE M (DO)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:M
Last Name:KIELTY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 E MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4809
Mailing Address - Country:US
Mailing Address - Phone:805-922-3548
Mailing Address - Fax:805-928-5609
Practice Address - Street 1:1430 E MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4809
Practice Address - Country:US
Practice Address - Phone:805-922-3548
Practice Address - Fax:805-928-5609
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1144208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502917Medicaid
11320126OtherCAQH
NVI03251Medicare UPIN
NV100502917Medicaid