Provider Demographics
NPI:1699765677
Name:CASTRO, KELLY CAJAHUARINGA (MD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CAJAHUARINGA
Last Name:CASTRO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:CAJAHUARINGA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:HR CREDENTIALING SERVICES
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-0000
Mailing Address - Fax:
Practice Address - Street 1:1111 AUGUSTA DR
Practice Address - Street 2:TANGLEWOOD CLINIC
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-2209
Practice Address - Country:US
Practice Address - Phone:713-442-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1281207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX146571803Medicaid
TX146571805Medicaid
TX146571802Medicaid
TX146571802Medicaid
TX8D2925Medicare PIN