Provider Demographics
NPI:1881887545
Name:KELLY, CECILY HOSTRUP (MD)
Entity type:Individual
Prefix:
First Name:CECILY
Middle Name:HOSTRUP
Last Name:KELLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 GENERATIONS STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW BRAUNFELS
Mailing Address - State:TX
Mailing Address - Zip Code:78130-0058
Mailing Address - Country:US
Mailing Address - Phone:830-214-6411
Mailing Address - Fax:830-626-8800
Practice Address - Street 1:794 GENERATIONS STE 100
Practice Address - Street 2:
Practice Address - City:NEW BRAUNFELS
Practice Address - State:TX
Practice Address - Zip Code:78130-0058
Practice Address - Country:US
Practice Address - Phone:830-214-6411
Practice Address - Fax:830-626-8800
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2151532-01Medicaid
TXTXB106371Medicare PIN
TX2151532-01Medicaid