Provider Demographics
NPI:1194010496
Name:SODVADIYA, JITENDRAKUMAR
Entity Type:Individual
Prefix:
First Name:JITENDRAKUMAR
Middle Name:
Last Name:SODVADIYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 E COURT ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:IL
Mailing Address - Zip Code:61944-2460
Mailing Address - Country:US
Mailing Address - Phone:217-465-4141
Mailing Address - Fax:
Practice Address - Street 1:727 E COURT ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:IL
Practice Address - Zip Code:61944-2460
Practice Address - Country:US
Practice Address - Phone:217-465-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6538207Q00000X
IL036135515207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine