KELLEY PARK MEDICAL CLINIC INC NPI 1942340625

NPI Information

NPI: 1942340625
Provider Name: KELLEY PARK MEDICAL CLINIC, INC
Classification: Clinic/Center - 261QP2300X
Entity Type: Organization

Specialization: Primary Care

CLIA Number: 05D2145845

Address:
749 STORY RD
SUITE 20
SAN JOSE, CA
ZIP 95122
Phone: (408) 794-2088
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KELLEY PARK MEDICAL CLINIC, INC is a primary care clinic center in San Jose, CA. KELLEY PARK MEDICAL CLINIC, INC NPI is 1942340625. The provider is registered as an organization entity type.

The provider's business location address is:

749 STORY RD
SUITE 20
SAN JOSE, CA
ZIP 95122-600
Phone: (408) 794-2088
Fax: (408) 292-2179

The provider's authorized official is Peter Linh Nguyen .
The authorized official title is Dr and has the following contact phone number (408) 794-2088.

The CLIA number assigned to this NPI record is 05D2145845 - physician office with a certificate type of Certificate for Provider-Performed Microscopy Procedures (PPMP).

The enumeration date for this NPI number is 2/8/2007 and was last updated on 8/15/2007.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No.	Taxonomy Code	Taxonomy Clasification	Taxonomy Specialization	License Number	License State	Primary
1	261QP2300X	Clinic/Center	Primary Care	20A7360	CALIFORNIA	Yes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No.	Other Provider Identifier	Other Provider Identifier Type	Other Provider Identifier State	Other Provider Identifier Issuer
1	023997	OTHER	CALIFORNIA	VFC
2	H27272	MEDICARE UPIN	CALIFORNIA
3	00AX73600	MEDICAID	CALIFORNIA
4	020A73601	MEDICARE ID-TYPE UNSPECIFIED	CALIFORNIA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 5/5/2024

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