Provider Demographics
NPI:1699878082
Name:KELVIN K MA MD INC PS
Entity type:Organization
Organization Name:KELVIN K MA MD INC PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:MA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-840-0406
Mailing Address - Street 1:PO BOX 1148
Mailing Address - Street 2:201 15TH AVE SW STE D
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0226
Mailing Address - Country:US
Mailing Address - Phone:253-840-0406
Mailing Address - Fax:253-840-3352
Practice Address - Street 1:201 15TH AVE SW
Practice Address - Street 2:STE D
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-0226
Practice Address - Country:US
Practice Address - Phone:253-840-0406
Practice Address - Fax:253-840-3352
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2084N0400X
WAMD000221572084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0067266OtherL & I
WA1302264Medicaid
WA1302264Medicaid
WAGAB27080Medicare ID - Type Unspecified