Provider Demographics
NPI:1780680496
Name:SHOULTZ, CHARLES A III (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:A
Last Name:SHOULTZ
Suffix:III
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 21327
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76702-1327
Mailing Address - Country:US
Mailing Address - Phone:254-399-5400
Mailing Address - Fax:254-772-8669
Practice Address - Street 1:7125 NEW SANGER AVE STE A
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76712-4054
Practice Address - Country:US
Practice Address - Phone:254-399-5400
Practice Address - Fax:254-772-8669
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6243207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX100345101OtherFIRSTCARE
TX1221938OtherFIRSTHEALTH
TX142799902OtherUNITED HEALTHCARE
TX117613302Medicaid
TX90032OtherSWHP
TX74178408876712A004OtherTRICARE
TX117613301Medicaid
TX4559831OtherAETNA
TX83W040OtherBLUE CROSS
TX820200Medicare PIN
TX1221938OtherFIRSTHEALTH
TX74178408876712A004OtherTRICARE
TX83W040Medicare PIN
060030152Medicare PIN