Provider Demographics
NPI:1104840594
Name:KELSOM CLINIC PA
Entity Type:Organization
Organization Name:KELSOM CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:OKORONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-254-7272
Mailing Address - Street 1:1202 W PIONEER DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75061-7308
Mailing Address - Country:US
Mailing Address - Phone:972-254-7272
Mailing Address - Fax:972-254-7575
Practice Address - Street 1:1202 W PIONEER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75061-7308
Practice Address - Country:US
Practice Address - Phone:972-254-7272
Practice Address - Fax:972-254-7575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2252207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX160977801Medicaid
TX00657UMedicare PIN