Provider Demographics
NPI:1609895077
Name:KELLY, JANE BARRETT (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:BARRETT
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:BARRETT
Other - Last Name:WETRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3860 CALLE FORTUNADA
Mailing Address - Street 2:SUITE 210
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-4800
Mailing Address - Country:US
Mailing Address - Phone:858-309-6300
Mailing Address - Fax:
Practice Address - Street 1:3030 CHILDRENS WAY
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-4232
Practice Address - Country:US
Practice Address - Phone:858-309-7702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG57904207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA93496Medicare UPIN
CA00G579040Medicare ID - Type Unspecified