Provider Demographics
NPI:1699707679
Name:SHETH, SUDHAKAR KRISHNADAS (MD)
Entity type:Individual
Prefix:DR
First Name:SUDHAKAR
Middle Name:KRISHNADAS
Last Name:SHETH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEMORIAL DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-1589
Mailing Address - Country:US
Mailing Address - Phone:217-875-2640
Mailing Address - Fax:217-875-3101
Practice Address - Street 1:2 MEMORIAL DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-1589
Practice Address - Country:US
Practice Address - Phone:217-875-2640
Practice Address - Fax:217-875-3101
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036059241207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036059241Medicaid
D140978Medicare UPIN
IL036059241Medicaid