Active NPI
Melody J a Desantiago, CPNP
- Pediatrics Physician
- Killeen, TX
National Provider Identifier
1982624193
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Pediatrics Physician
- License
- AP113575
- Practice address
- 4102 S Clear Creek Rd Ste 107
Killeen, TX 76549-5954 - Phone
- (254) 526-8300
- Fax
- (254) 526-4828
- NPI assigned
- Jul 20, 2006
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | AP113575 | TX | Primary |
Addresses
Primary practice location
4102 S Clear Creek Rd Ste 107
Killeen, TX 76549-5954
Mailing address
503 W Vardeman Ave
Killeen, TX 76541-7962
Phone (254) 501-3793
Other practice location 1
2301 S Clear Creek Rd
Suite 226
Killeen, TX 76549-4143
Phone (254) 526-8300
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 367312101 | Medicaid | TX |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Certified Pediatric Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| AP113575 | TX | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Killeen Pediatric Care Clinic, P.a. | Pediatrics | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153353600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1658361600000",
"number": "1982624193",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "503 W VARDEMAN AVE",
"city": "KILLEEN",
"state": "TX",
"postal_code": "765417962",
"telephone_number": "254-501-3793"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4102 S CLEAR CREEK RD STE 107",
"city": "KILLEEN",
"state": "TX",
"postal_code": "765495954",
"telephone_number": "254-526-8300",
"fax_number": "254-526-4828"
}
],
"practiceLocations": [
{
"address_1": "2301 S Clear Creek Rd",
"address_2": "Suite 226",
"address_purpose": "LOCATION",
"city": "Killeen",
"state": "TX",
"postal_code": "765494143",
"country_code": "US",
"telephone_number": "254-526-8300",
"fax_number": "254-526-4828",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "DESANTIAGO",
"first_name": "MELODY",
"middle_name": "J A",
"credential": "CPNP",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-07-20",
"last_updated": "2022-07-21",
"status": "A"
},
"taxonomies": [
{
"code": "208000000X",
"taxonomy_group": "",
"desc": "Pediatrics",
"state": "TX",
"license": "AP113575",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "367312101",
"state": "TX"
}
],
"endpoints": [],
"other_names": []
}Other providers in Killeen, TX
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.