Provider Demographics
NPI:1073507703
Name:KELLY, DEBORAH S (MD)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:S
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:SIMON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:51 N 39TH ST
Mailing Address - Street 2:SCHEIE EYE INSTITUTE
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-2640
Mailing Address - Country:US
Mailing Address - Phone:215-662-8113
Mailing Address - Fax:215-243-4695
Practice Address - Street 1:51 N 39TH ST
Practice Address - Street 2:SCHEIE EYE INSTITUTE
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-2640
Practice Address - Country:US
Practice Address - Phone:215-662-8113
Practice Address - Fax:215-243-4695
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2012-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068639L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1239987Medicaid
PA029834Medicare PIN
PA1239987Medicaid