Provider Demographics
NPI:1790780468
Name:STUMBO, KEELI L (MD)
Entity Type:Individual
Prefix:DR
First Name:KEELI
Middle Name:L
Last Name:STUMBO
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 1:1201 HEWITT DR STE 105B
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-8833
Mailing Address - Country:US
Mailing Address - Phone:254-230-4225
Mailing Address - Fax:
Practice Address - Street 1:1201 HEWITT DR STE 105B
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-8833
Practice Address - Country:US
Practice Address - Phone:254-230-4225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1469208VP0000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140921106Medicaid
TX140921106Medicaid
TX8A7322Medicare PIN