Provider Demographics
NPI:1982722674
Name:KELLEY, JONATHAN M (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:KELLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:661 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:SIERRA MADRE
Mailing Address - State:CA
Mailing Address - Zip Code:91024-1445
Mailing Address - Country:US
Mailing Address - Phone:626-355-1984
Mailing Address - Fax:
Practice Address - Street 1:661 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:SIERRA MADRE
Practice Address - State:CA
Practice Address - Zip Code:91024-1445
Practice Address - Country:US
Practice Address - Phone:626-355-1984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26177207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G261770Medicaid
CA00G261770Medicaid
CAA42931Medicare UPIN