Provider Demographics
NPI:1699776989
Name:SHUDA, KIMBERLY A (DC)
Entity type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:A
Last Name:SHUDA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4022 BLACKHAWK RD
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-7164
Mailing Address - Country:US
Mailing Address - Phone:309-786-0883
Mailing Address - Fax:309-786-8025
Practice Address - Street 1:4022 BLACKHAWK RD
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-7164
Practice Address - Country:US
Practice Address - Phone:309-786-0883
Practice Address - Fax:309-786-8025
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006936111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
350029347OtherRR MEDICARE
IL038006936Medicaid
IL08128067OtherBCBS
975880Medicare ID - Type Unspecified
350029347OtherRR MEDICARE