Provider Demographics
NPI:1659702942
Name:KELLEY, BENJAMIN F (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:F
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8646
Mailing Address - Fax:858-554-6271
Practice Address - Street 1:10820 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1036
Practice Address - Country:US
Practice Address - Phone:858-554-8646
Practice Address - Fax:858-554-6271
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA155759207N00000X, 207ND0900X, 207ND0101X
MN107728207N00000X
MN58373207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400158332Medicare PIN