Healthcare Provider Details

I. General information

NPI: 1659567824
Provider Name (Legal Business Name): KELVIN DEMONT EXUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 12/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7808 CLODUS FIELDS DR
DALLAS TX
75251-2206
US

IV. Provider business mailing address

7808 CLODUS FIELDS DR
DALLAS TX
75251-2206
US

V. Phone/Fax

Practice location:
  • Phone: 972-770-1032
  • Fax: 469-484-1785
Mailing address:
  • Phone: 972-770-1032
  • Fax: 469-484-1785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number200701556
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: