Provider Demographics
NPI:1437101409
Name:SHASTRI, PRIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:
Last Name:SHASTRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PRIORITY
Other - Middle Name:ONE
Other - Last Name:HEALTHCARE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17029 KERRY AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8775
Mailing Address - Country:US
Mailing Address - Phone:708-213-7975
Mailing Address - Fax:708-213-7975
Practice Address - Street 1:17901 GOVERNORS HWY STE 100
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1145
Practice Address - Country:US
Practice Address - Phone:708-213-7975
Practice Address - Fax:708-213-7975
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036115357207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-115357OtherIL LICENSE NUMBER
ILI36206Medicaid