Provider Demographics
NPI:1447263694
Name:DOULENS, KEVIN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:MICHAEL
Last Name:DOULENS
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2598 W WHITE RIVER BLVD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-5251
Practice Address - Country:US
Practice Address - Phone:765-702-2817
Practice Address - Fax:317-222-2198
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96452207X00000X
MS24068207XX0005X
LAMD.207745207XX0005X
IN01087328A207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2761041-00Medicaid
GA335618802AMedicaid
LA2390562Medicaid
FLP01087491OtherMEDICARE RAILROAD
MS00074040Medicaid
GA335618802AMedicaid
FLI71710Medicare UPIN
FL2761041-00Medicaid
FLAC258XMedicare PIN