Provider Demographics
NPI:1861408205
Name:KALLAL, KEVIN J (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:KALLAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 N RUFE SNOW DR
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-4226
Mailing Address - Country:US
Mailing Address - Phone:817-431-0606
Mailing Address - Fax:817-379-0155
Practice Address - Street 1:240 N RUFE SNOW DR
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-4226
Practice Address - Country:US
Practice Address - Phone:817-431-0606
Practice Address - Fax:817-379-0155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB156373Medicare PIN
TXC48326Medicare UPIN
TX00G90WMedicare PIN