Provider Demographics
NPI:1083685085
Name:KELLEY, LEON R (MD)
Entity Type:Individual
Prefix:DR
First Name:LEON
Middle Name:R
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:STE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-636-4300
Mailing Address - Fax:858-636-4319
Practice Address - Street 1:292 EUCLID AVE
Practice Address - Street 2:220
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114
Practice Address - Country:US
Practice Address - Phone:619-262-8624
Practice Address - Fax:619-262-6639
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC27643208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC27643OtherMD LICENSE
CAC27643OtherMD LICENSE