Healthcare Provider Details

I. General information

NPI: 1154313971
Provider Name (Legal Business Name): KELLY DEAN SKANCHY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 CRAVEN ST BLDG 3300 NAVAL HEALTH CLINIC NAVAL STATION SAN DIEGO
SAN DIEGO CA
92136-5599
US

IV. Provider business mailing address

2450 CRAVEN ST BLDG 3300 NAVAL HEALTH CLINIC NAVAL BASE SAN DIEGO
SAN DIEGO CA
92136-5599
US

V. Phone/Fax

Practice location:
  • Phone: 619-556-5936
  • Fax: 619-556-9419
Mailing address:
  • Phone: 619-556-5936
  • Fax: 619-556-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD044935L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberGFE83510
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: