Provider Demographics
NPI:1417954470
Name:JERSTAD, KELLY MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:JERSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MICHELE
Other - Last Name:BINSTOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4950 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2864
Mailing Address - Country:US
Mailing Address - Phone:605-330-9619
Mailing Address - Fax:605-330-9503
Practice Address - Street 1:4950 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2864
Practice Address - Country:US
Practice Address - Phone:605-330-9619
Practice Address - Fax:605-330-9503
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5248207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD5900450Medicaid
SD41535Medicare ID - Type UnspecifiedMEDICARE#
SD5900450Medicaid