Provider Demographics
NPI:1619061827
Name:SHAH, JITENDRA J (MD)
Entity Type:Individual
Prefix:DR
First Name:JITENDRA
Middle Name:J
Last Name:SHAH
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 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3105
Mailing Address - Country:US
Mailing Address - Phone:309-655-3453
Mailing Address - Fax:309-655-2938
Practice Address - Street 1:420 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-3105
Practice Address - Country:US
Practice Address - Phone:309-655-3453
Practice Address - Fax:309-655-2938
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0539722080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053972Medicaid
IL036053972Medicaid
ILIL3270065Medicare PIN
ILL64780Medicare ID - Type Unspecified