Provider Demographics
NPI:1396338513
Name:ABDO, KELIFA KEDIR SR
Entity type:Individual
Prefix:
First Name:KELIFA
Middle Name:KEDIR
Last Name:ABDO
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18112 MORETO LOOP
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-5333
Mailing Address - Country:US
Mailing Address - Phone:702-215-1899
Mailing Address - Fax:
Practice Address - Street 1:18112 MORETO LOOP
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-5333
Practice Address - Country:US
Practice Address - Phone:702-215-1899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2020700079172A00000X
TX36141020172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty