Provider Demographics
NPI:1528038312
Name:CUNNINGHAM, FRED KELLY (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:KELLY
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5300 BEE CAVES RD STE 260
Mailing Address - Street 2:
Mailing Address - City:WEST LAKE HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:78746-5226
Mailing Address - Country:US
Mailing Address - Phone:512-410-0767
Mailing Address - Fax:512-649-7402
Practice Address - Street 1:5300 BEE CAVE ROAD BLDG I
Practice Address - Street 2:STE 260
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78746-5226
Practice Address - Country:US
Practice Address - Phone:512-410-0767
Practice Address - Fax:512-649-7402
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG4944207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1278600001OtherMEDICARE SUPPLIER NUMBER
TX131598805Medicaid
TXC14955Medicare UPIN
TX1278600001Medicare NSC
TX131598805Medicaid