Provider Demographics
NPI:1962568840
Name:WOYEWODZIC, KELLY THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:THOMAS
Last Name:WOYEWODZIC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:THOMAS
Other - Last Name:AZAR-WOYEWODZIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:10323 SANTA MONICA BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:310-499-1350
Mailing Address - Fax:310-360-0868
Practice Address - Street 1:10323 SANTA MONICA BLVD.
Practice Address - Street 2:SUITE 101
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025
Practice Address - Country:US
Practice Address - Phone:310-499-1350
Practice Address - Fax:310-360-0868
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2295042084P0800X
CAA927402084P0800X
CA927402084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry