Provider Demographics
NPI:1457491227
Name:CUNNINGHAM, KELLY EILLEEN (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:EILLEEN
Last Name:CUNNINGHAM
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 1:731 E SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6377
Mailing Address - Country:US
Mailing Address - Phone:817-912-8800
Mailing Address - Fax:817-912-8810
Practice Address - Street 1:731 E SOUTHLAKE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6377
Practice Address - Country:US
Practice Address - Phone:817-912-8800
Practice Address - Fax:817-912-8810
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7410207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM40883272Medicaid
TX281181201Medicaid
TX8CQ192OtherBCBSTX
TXTXB119760Medicare PIN
TXP00955292Medicare PIN