Provider Demographics
NPI:1104838887
Name:MAEDO, KELLY (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MAEDO
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 1:818 ROYAL ADELADE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4444
Mailing Address - Country:US
Mailing Address - Phone:979-757-1103
Mailing Address - Fax:
Practice Address - Street 1:3100 BUDDY OWENS AVE
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-6464
Practice Address - Country:US
Practice Address - Phone:956-971-0404
Practice Address - Fax:956-971-0408
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5032207N00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157550803Medicaid
TX8S6084OtherBCBS
TX157550803Medicaid
TX8S6084OtherBCBS