Provider Demographics
NPI:1245617190
Name:DEAGOSTINO-KELLY, MARY REBECCA (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:REBECCA
Last Name:DEAGOSTINO-KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:3701 MARKET ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-5505
Mailing Address - Country:US
Mailing Address - Phone:215-662-6035
Mailing Address - Fax:215-349-5228
Practice Address - Street 1:3701 MARKET ST FL 3
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5505
Practice Address - Country:US
Practice Address - Phone:215-662-6035
Practice Address - Fax:215-349-5228
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD467434207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology