Provider Demographics
NPI:1154313971
Name:SKANCHY, KELLY DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:DEAN
Last Name:SKANCHY
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 1:2450 CRAVEN ST BLDG 3300
Mailing Address - Street 2:NAVAL HEALTH CLINIC NAVAL BASE SAN DIEGO
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5599
Mailing Address - Country:US
Mailing Address - Phone:619-556-5936
Mailing Address - Fax:619-556-9419
Practice Address - Street 1:2450 CRAVEN ST BLDG 3300
Practice Address - Street 2:NAVAL HEALTH CLINIC NAVAL STATION SAN DIEGO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5599
Practice Address - Country:US
Practice Address - Phone:619-556-5936
Practice Address - Fax:619-556-9419
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044935L207QS0010X
CAGFE83510207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVAD0000Medicare UPIN