Provider Demographics
NPI:1568461226
Name:SHOULTS, KEVIN D (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:SHOULTS
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:5330 OVERPASS RD STE 110
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2300
Practice Address - Country:US
Practice Address - Phone:737-999-6200
Practice Address - Fax:737-999-6201
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-15
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036093083207L00000X, 207LP2900X
TXR8105207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036093083Medicaid
IL04932058OtherBLUE SHIELD OF ILLINOIS
ILG25935Medicare UPIN
IL04932058OtherBLUE SHIELD OF ILLINOIS