Provider Demographics
NPI:1538399738
Name:KELLY, JASON STUART (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:STUART
Last Name:KELLY
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 1:478 CROSSWIND DR
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-2778
Mailing Address - Country:US
Mailing Address - Phone:904-261-6221
Mailing Address - Fax:
Practice Address - Street 1:1250 S 18TH ST
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1902
Practice Address - Country:US
Practice Address - Phone:904-261-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY252864207L00000X
FLME107561207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology