Provider Demographics
NPI:1174529523
Name:IP, KAM (MD)
Entity type:Individual
Prefix:DR
First Name:KAM
Middle Name:
Last Name:IP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 RIVER NORTH BLVD
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-1803
Mailing Address - Country:US
Mailing Address - Phone:254-968-6051
Mailing Address - Fax:254-968-4204
Practice Address - Street 1:150 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-968-6051
Practice Address - Fax:254-968-4204
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE9244207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115783100OtherFIRST CARE PROVIDER NUMBE
TX814737OtherBCBS PROVIDER NUMBER
TX4362776OtherAETNA PROVIDER NUMBER
TN1840110OtherCIGNA PROVIDER NUMBER
TX9300160802OtherRAILROAD MEDICARE
TX134110903Medicaid
TX98464611OtherUNITED HEALTHCARE PROV NO
TX4362776OtherAETNA PROVIDER NUMBER
TN1840110OtherCIGNA PROVIDER NUMBER