Basic Information
| Provider Information | |||||||||
| NPI: | 1083606776 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PFEIFER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 SOUTHPOINT BLVD | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949546858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075597500 | ||||||||
| FaxNumber: | 7075597570 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 SOUTHPOINT BLVD | ||||||||
| Address2: | |||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949546858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075597500 | ||||||||
| FaxNumber: | 7075597570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 12/17/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A66577 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | HAP70696F | 05 | CA | MEDICAID | ZZZ18742Z | 01 | CA | ISSUER MEDICARE | OTHER | FHC70696F | 05 | CA | MEDICAID | A66577 | 01 | CA | LICENSE | OTHER | BCP70696F | 05 | CA | MEDICAID |