Basic Information
| Provider Information | |||||||||
| NPI: | 1821164690 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLMAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018707 | ||||||||
| FaxNumber: | 3103018751 | ||||||||
| Practice Location | |||||||||
| Address1: | 4560 ADMIRALTY WAY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MARINA DEL REY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902925424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106561770 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207P00000X | 20A5062 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX50620 | 05 | CA | MEDICAID |