Provider Demographics
NPI:1528214624
Name:SHANKARAN, VIDYA (MD)
Entity Type:Individual
Prefix:
First Name:VIDYA
Middle Name:
Last Name:SHANKARAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 W LINCOLN ST
Mailing Address - Street 2:STE 500
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1900
Mailing Address - Country:US
Mailing Address - Phone:618-277-7400
Mailing Address - Fax:
Practice Address - Street 1:340 W LINCOLN ST
Practice Address - Street 2:STE 500
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1900
Practice Address - Country:US
Practice Address - Phone:618-277-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH20106208200000X
IL125050724208600000X
IL036134925208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036134925OtherILLINOIS DEPT OF FINANCIAL AND PROFESSIONAL REGULATION