Provider Demographics
NPI:1588662886
Name:MCCULLAGH, KELLY ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:MCCULLAGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:21700 KINGSLAND BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77450-2513
Mailing Address - Country:US
Mailing Address - Phone:281-398-8639
Mailing Address - Fax:281-398-5019
Practice Address - Street 1:21700 KINGSLAND BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77450-2513
Practice Address - Country:US
Practice Address - Phone:281-398-8639
Practice Address - Fax:281-398-5019
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXJ0113207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX045349001Medicaid
TX045349001Medicaid
TX86Z232Medicare PIN