Provider Demographics
NPI:1104838887
Name:MAEDO, KELLY (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAEDO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2911 TEXAS AVE S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5387
Mailing Address - Country:US
Mailing Address - Phone:979-764-2882
Mailing Address - Fax:979-764-2828
Practice Address - Street 1:2911 TEXAS AVE S
Practice Address - Street 2:SUITE 103
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5387
Practice Address - Country:US
Practice Address - Phone:979-764-2882
Practice Address - Fax:979-764-2828
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5032207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S6084OtherBCBS
TX157550803Medicaid
TX157550803Medicaid
TX8S6084OtherBCBS