Basic Information
Provider Information | |||||||||
NPI: | 1659702942 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KELLEY | ||||||||
FirstName: | BENJAMIN | ||||||||
MiddleName: | F | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10790 RANCHO BERNARDO RD | ||||||||
Address2: |   | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921275705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585548646 | ||||||||
FaxNumber: | 8585546271 | ||||||||
Practice Location | |||||||||
Address1: | 10820 N TORREY PINES RD | ||||||||
Address2: |   | ||||||||
City: | LA JOLLA | ||||||||
State: | CA | ||||||||
PostalCode: | 920371036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585548646 | ||||||||
FaxNumber: | 8585546271 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/11/2013 | ||||||||
LastUpdateDate: | 12/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | A155759 | CA | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207N00000X | 107728 | MN | N |   | Allopathic & Osteopathic Physicians | Dermatology |   | 207ND0900X | A155759 | CA | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0900X | 58373 | MN | N |   | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207ND0101X | A155759 | CA | Y |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery |
No ID Information.