Provider Demographics
NPI:1881686343
Name:SHADLE, KATHLEEN (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:SHADLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6565 FANNIN ST
Mailing Address - Street 2:SUITE AX121B
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2703
Mailing Address - Country:US
Mailing Address - Phone:713-441-4800
Mailing Address - Fax:713-793-1300
Practice Address - Street 1:6565 FANNIN ST
Practice Address - Street 2:SUITE AX121B
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2703
Practice Address - Country:US
Practice Address - Phone:713-441-4800
Practice Address - Fax:713-793-1300
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ10382085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX129641008OtherMEDICAID CSHCN
TX129641010Medicaid
TXP00747796OtherRR MEDICARE
TX129641007Medicaid
TX129641009Medicaid
TX8BN489OtherBLUE CROSS BLUE SHIELD
TX129641001Medicaid
TX85471ROtherBLUE CROSS
TX8FU326OtherBLUE CROSS BLUE SHIELD
TX129641006Medicaid
TX129641007Medicaid
TX85471ROtherBLUE CROSS
TX129641006Medicaid
TX129641001Medicaid
TX483950ZSVEMedicare PIN
TX8L6294Medicare PIN