Provider Demographics
NPI:1376591032
Name:KELLUM, MICHAEL W
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:W
Last Name:KELLUM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 CENTRAL EXPY N
Mailing Address - Street 2:STE. 110
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6103
Mailing Address - Country:US
Mailing Address - Phone:972-727-9877
Mailing Address - Fax:972-727-5015
Practice Address - Street 1:1105 CENTRAL EXPY N
Practice Address - Street 2:STE. 110
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-6103
Practice Address - Country:US
Practice Address - Phone:972-727-9877
Practice Address - Fax:972-727-5015
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG8211207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXB23891Medicare UPIN