Provider Demographics
NPI:1154359503
Name:SHEPHERD, KELVIN DWAYNE (DO)
Entity type:Individual
Prefix:DR
First Name:KELVIN
Middle Name:DWAYNE
Last Name:SHEPHERD
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 TELEPHONE RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77023-1840
Mailing Address - Country:US
Mailing Address - Phone:713-926-6229
Mailing Address - Fax:713-926-9105
Practice Address - Street 1:927 E SHAW AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77506-1430
Practice Address - Country:US
Practice Address - Phone:713-982-5900
Practice Address - Fax:713-982-5944
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172312401Medicaid
TXI27482Medicare UPIN
TX8E0135Medicare PIN
TX172312401Medicaid