Basic Information
| Provider Information | |||||||||
| NPI: | 1609895077 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLY | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | BARRETT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WETRICH | ||||||||
| OtherFirstName: | JANE | ||||||||
| OtherMiddleName: | BARRETT | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3860 CALLE FORTUNADA | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3030 CHILDRENS WAY | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583097702 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 04/03/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | G57904 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.