Provider Demographics
NPI:1184804999
Name:JON P. KELLY, M.D., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:JON P. KELLY, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:PEMBROKE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-743-0100
Mailing Address - Street 1:255 N ELM ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3431
Mailing Address - Country:US
Mailing Address - Phone:760-743-0100
Mailing Address - Fax:760-743-1414
Practice Address - Street 1:255 N ELM ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3431
Practice Address - Country:US
Practice Address - Phone:760-743-0100
Practice Address - Fax:760-743-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45013174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45013Medicare UPIN