Provider Demographics
NPI:1992795611
Name:FLOOD-SHAFFER, KELLIE F (MD)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:F
Last Name:FLOOD-SHAFFER
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:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78624-0835
Mailing Address - Country:US
Mailing Address - Phone:830-990-1404
Mailing Address - Fax:
Practice Address - Street 1:506 W WINDCREST ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:TX
Practice Address - Zip Code:78624-4639
Practice Address - Country:US
Practice Address - Phone:830-990-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH5234207V00000X
OH35-092222207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPENDINGMedicaid
TXPENDINGOtherBCBSTX - WCCA
KY7100056510Medicaid
OH2861792Medicaid
TX8FE478OtherBCBS
KY7100056510Medicaid
TX8FE478OtherBCBS