Provider Demographics
NPI:1437151271
Name:MONIPPALLIL, SHANTHA MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:SHANTHA
Middle Name:MATTHEW
Last Name:MONIPPALLIL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SHANTHA
Other - Middle Name:MATTHEW
Other - Last Name:MONIPPALLIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1901 S 4TH ST
Mailing Address - Street 2:SAME
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-4187
Mailing Address - Country:US
Mailing Address - Phone:217-347-7600
Mailing Address - Fax:
Practice Address - Street 1:1901 S 4TH ST
Practice Address - Street 2:SAME
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-4187
Practice Address - Country:US
Practice Address - Phone:217-347-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036058112207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD13944Medicare UPIN