Provider Demographics
NPI:1558387217
Name:DAVE, SHRUTI M (MD)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:M
Last Name:DAVE
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 1:602 W. UNIVERSITY AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT - NCW4
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2530
Mailing Address - Country:US
Mailing Address - Phone:217-383-6792
Mailing Address - Fax:740-395-8592
Practice Address - Street 1:1813 W. KIRBY AVENUE
Practice Address - Street 2:ENDOCRINOLOGY
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61821
Practice Address - Country:US
Practice Address - Phone:217-383-3490
Practice Address - Fax:217-383-3439
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084113207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7030597OtherAETNA
OH000000349199OtherANTHEM
OH2503973Medicaid
OH000000349199OtherANTHEM
OHI20373Medicare UPIN
IL208905138Medicare PIN
OH2503973Medicaid