Healthcare Provider Details

I. General information

NPI: 1649270059
Provider Name (Legal Business Name): DAN KELLY EIDMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 07/22/2023
Certification Date: 07/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 TWELVE OAKS DR.,
HOUSTON TX
77027
US

IV. Provider business mailing address

4200 TWELVE OAKS DR.,
HOUSTON TX
77027
US

V. Phone/Fax

Practice location:
  • Phone: 713-980-7900
  • Fax: 713-600-1788
Mailing address:
  • Phone: 713-980-7900
  • Fax: 713-600-1788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE4316
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberE4316
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: