Provider Demographics
NPI:1447217724
Name:UPADHYA, SHASHI B (MD)
Entity Type:Individual
Prefix:DR
First Name:SHASHI
Middle Name:B
Last Name:UPADHYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 JOHN DEERE ROAD, SUITE 200
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6897
Mailing Address - Country:US
Mailing Address - Phone:309-779-4230
Mailing Address - Fax:309-779-4305
Practice Address - Street 1:600 JOHN DEERE ROAD, SUITE 200
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6897
Practice Address - Country:US
Practice Address - Phone:309-779-4230
Practice Address - Fax:309-779-4305
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2009-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036044906207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036044906Medicaid
ILL67355OtherMEDICARE PTAN
C37633Medicare UPIN