Provider Demographics
NPI:1275859803
Name:HA, KELLI Y (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:Y
Last Name:HA
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 1:6550 FANNIN ST STE 749
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2738
Mailing Address - Country:US
Mailing Address - Phone:713-441-7465
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST STE 749
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2738
Practice Address - Country:US
Practice Address - Phone:713-441-7465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-07
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP37262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360013205Medicaid
TX360013203Medicaid