Healthcare Provider Details

I. General information

NPI: 1205866811
Provider Name (Legal Business Name): JON P KELLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2777 JEFFERSON ST SUITE 100
CARLSBAD CA
92008-1743
US

IV. Provider business mailing address

PO BOX 390005
SAN DIEGO CA
92149-0005
US

V. Phone/Fax

Practice location:
  • Phone: 760-434-0033
  • Fax: 760-434-0027
Mailing address:
  • Phone: 619-746-6530
  • Fax: 619-746-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA45013
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License NumberA45013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: