Healthcare Provider Details

I. General information

NPI: 1114987658
Provider Name (Legal Business Name): KELLY SHANNON KEEFE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3969 4TH AVE SUITE 301
SAN DIEGO CA
92103
US

IV. Provider business mailing address

3969 4TH AVE SUITE 301
SAN DIEGO CA
92103
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6702
  • Fax: 619-532-7272
Mailing address:
  • Phone: 619-291-6191
  • Fax: 619-291-0049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberA48069
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberA48069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: