Provider Demographics
NPI:1760480750
Name:SHOUDEL, JOHN ANDREW (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANDREW
Last Name:SHOUDEL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 N RUTLEDGE ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-6700
Mailing Address - Country:US
Mailing Address - Phone:217-652-3816
Mailing Address - Fax:
Practice Address - Street 1:2070 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4174
Practice Address - Country:US
Practice Address - Phone:217-698-6228
Practice Address - Fax:217-698-7241
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILIL016004443213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016-004443Medicaid
ILU12649Medicare UPIN
IL256510036Medicare PIN
IL4804470001Medicare NSC
IL016-004443Medicaid