Provider Demographics
NPI:1013949635
Name:LALLY, KEVIN P (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:P
Last Name:LALLY
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:PO BOX 201088
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77216-1088
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:1400
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-7234
Practice Address - Fax:713-512-2221
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH9668208600000X, 2086S0120X, 2086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137118905Medicaid
TX137118917Medicaid
TX137118918OtherMEDICAID-CSHCN
TX82M033OtherBCBS
TX81Z193OtherBCBS
TX137118901OtherCSHCN