Provider Demographics
NPI:1316331960
Name:SHADICK, JELENA KRAVIC (MD)
Entity type:Individual
Prefix:
First Name:JELENA
Middle Name:KRAVIC
Last Name:SHADICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JELENA
Other - Middle Name:
Other - Last Name:KRAVIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2700 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904
Practice Address - Country:US
Practice Address - Phone:904-633-4199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-21
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI68579208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program