Provider Demographics
NPI:1891965505
Name:KEVIN J KALLAL MD PA
Entity type:Organization
Organization Name:KEVIN J KALLAL MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KALLAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-431-0606
Mailing Address - Street 1:5015 FORT AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-5828
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1861408205OtherINDIVIDUAL NPI
TX1861408205OtherINDIVIDUAL NPI