Provider Demographics
NPI:1053584086
Name:GULLOTTA, KELLY ELEANOR MOULTON (MD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:ELEANOR MOULTON
Last Name:GULLOTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ELEANOR
Other - Last Name:MOULTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX 635
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-273-3919
Mailing Address - Fax:585-461-3614
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-273-3919
Practice Address - Fax:585-461-3614
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-10
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT559182080N0001X
NY2467622080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine