1174518625 NPI number — DANIEL H KELLUM SR. DO

Table of content: DANIEL H KELLUM SR. DO (NPI 1174518625)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174518625 NPI number — DANIEL H KELLUM SR. DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KELLUM
Provider First Name:
DANIEL
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174518625
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7323 MARBACH RD STE 104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78227-1905
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-674-0257
Provider Business Mailing Address Fax Number:
210-369-9064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7323 MARBACH RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78227-1905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-674-0257
Provider Business Practice Location Address Fax Number:
210-369-9064
Provider Enumeration Date:
09/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  E2252 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 193200000X . This is a "PRIMARY CARE GROUP TAXONOMY#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 00295N . This is a "MEDICARE GRP#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1174518625 . This is a "DANIEL H. KELLUM, SR, DO / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1508813494 . This is a "KELLUM MEDICAL GROUP, PA / NPI#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 207Q00000X . This is a "PROVIDER TAXONOMY#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: H2252 . This is a "LICENSE#" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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