Provider Demographics
NPI:1134236623
Name:KELLY, THOMAS GERALD (MD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:GERALD
Last Name:KELLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:550 WASHINGTON ST
Mailing Address - Street 2:STE #300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2213
Mailing Address - Country:US
Mailing Address - Phone:619-297-5437
Mailing Address - Fax:619-297-4567
Practice Address - Street 1:550 WASHINGTON ST
Practice Address - Street 2:STE #300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2213
Practice Address - Country:US
Practice Address - Phone:619-297-5437
Practice Address - Fax:619-297-4567
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA887902080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A887900Medicaid