Provider Demographics
NPI:1285805952
Name:SHAVER, KERRY EUGENE (MD)
Entity type:Individual
Prefix:DR
First Name:KERRY
Middle Name:EUGENE
Last Name:SHAVER
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 5478
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70302-5478
Mailing Address - Country:US
Mailing Address - Phone:940-704-8415
Mailing Address - Fax:
Practice Address - Street 1:604 N ACADIA RD
Practice Address - Street 2:STE 410
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301
Practice Address - Country:US
Practice Address - Phone:985-493-4004
Practice Address - Fax:985-493-4007
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2018-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA204575207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAP01169638OtherRAILROAD MEDICARE
LA1500640Medicaid
LAP01169638OtherRAILROAD MEDICARE