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Organization
KELLUM MEDICAL GROUP, PA
Active
Organization
KELLUM MEDICAL GROUP, PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KRISTI BRAKER (CONTRACT MANAGEMENT)
(210) 674-0257
Entity
Organization
Contact information
Practice address
7323 MARBACH RD STE 104, SAN ANTONIO, TX 78227-1905
(210) 674-0257
(210) 369-9064
Mailing address
7323 MARBACH RD STE 104, SAN ANTONIO, TX 78227-1905
(210) 674-0257
(210) 369-9064
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
363A00000X
Physician Assistant
—
—
363AM0700X
Medical Physician Assistant
—
—
363LF0000X
Family Nurse Practitioner
—
—
363LP0200X
Pediatric Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00295N
MEDICARE GROUP PTAN#
TX
01
—
1063070308
MANUELA BERRY, NP-C / NPI#
TX
01
—
1174518625
DANIEL H KELLUM SR., DO - NPI
TX
01
—
1265413264
ALICE T. BLACKMON, NP-C / NPI#
TX
01
—
1346646510
MATTHEW ARISMENDEZ, PA-C / NPI#
TX
01
—
1366623639
KIMBERLY 'KIM' DIAZ, PA-C
TX
05
—
1508813494
—
TX
01
—
1588641377
SALVADOR VAZQUEZ, MD / NPI#
TX
01
—
193200000X
GROUP TAXONOMY
TX
01
—
45D0671939
CLIA - KELLUM MEDICAL GROUP, PA
TX
01
—
45D1026258
CLIA - KELLUM MEDICAL GROUP, PA - PEDIATRICS
TX
01
—
CH6982
MEDICARE RR GROUP PTAN#
TX
01
—
R-14400
RADIOLOGY & X-RAY CERT#
TX
Enumeration date
05/27/2006
Last updated
03/09/2026
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