Provider Demographics
NPI:1083888119
Name:EUBANK, KELLEY VIDULICH (MD)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:VIDULICH
Last Name:EUBANK
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 1:5252 WESTCHESTER ST STE 242
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77005-4141
Mailing Address - Country:US
Mailing Address - Phone:713-568-0708
Mailing Address - Fax:713-568-0709
Practice Address - Street 1:5252 WESTCHESTER ST STE 242
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005
Practice Address - Country:US
Practice Address - Phone:713-568-0708
Practice Address - Fax:713-568-0709
Is Sole Proprietor?:No
Enumeration Date:2008-04-18
Last Update Date:2019-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM4621207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology