Provider Demographics
NPI:1205866811
Name:KELLY, JON P (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:P
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 390005
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92149-0005
Mailing Address - Country:US
Mailing Address - Phone:619-746-6530
Mailing Address - Fax:619-746-6528
Practice Address - Street 1:2777 JEFFERSON ST
Practice Address - Street 2:SUITE 100
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1743
Practice Address - Country:US
Practice Address - Phone:760-434-0033
Practice Address - Fax:760-434-0027
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA45013207X00000X, 207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG30017Medicare UPIN
CA1232030001Medicare NSC
CAA45013Medicare PIN