Provider Demographics
NPI:1699717124
Name:SHAMLOU, K KEVIN (MD)
Entity type:Individual
Prefix:DR
First Name:K
Middle Name:KEVIN
Last Name:SHAMLOU
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 1:1673 MASON AVE
Mailing Address - Street 2:SUITE# 305
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-5515
Mailing Address - Country:US
Mailing Address - Phone:386-274-7118
Mailing Address - Fax:386-274-6173
Practice Address - Street 1:1673 MASON AVE
Practice Address - Street 2:SUITE# 305
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5515
Practice Address - Country:US
Practice Address - Phone:386-274-7118
Practice Address - Fax:386-274-6173
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00639602085B0100X, 2085N0700X, 2085N0904X, 2085P0229X, 2085R0202X, 2085R0203X, 2085R0204X, 2085U0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
No2085R0203XAllopathic & Osteopathic PhysiciansRadiologyTherapeutic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL68718OtherBLUE CROSS BLUE SHIELD
FL375394800Medicaid
FL68718OtherBLUE CROSS BLUE SHIELD
FL68718EMedicare PIN
FLP00140661Medicare PIN
FLF81700Medicare UPIN
FL68718YMedicare PIN