Provider Demographics
NPI:1003900119
Name:TJELMELAND, KELLY EUGENE (M D)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EUGENE
Last Name:TJELMELAND
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 BULL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4220 BULL CREEK RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-6026
Practice Address - Country:US
Practice Address - Phone:512-617-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7860208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX110753404Medicaid
TX8AQ830OtherBCBS INDIVIDUAL NUMBER
TX8A4014Medicare PIN
TX8AQ830OtherBCBS INDIVIDUAL NUMBER