=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033772132
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLEY EUBANK DERMATOLOGY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2019
-----------------------------------------------------
Last Update Date | 05/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5252 WESTCHESTER ST STE 242
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-4141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-568-0708
-----------------------------------------------------
Fax | 713-568-0709
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3704 PLUMB ST
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77005-2810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KELLEY EUBANK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 713-568-0708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------