Provider Demographics
NPI:1891724241
Name:IYENGAR, SHOBHA S (MD)
Entity Type:Individual
Prefix:DR
First Name:SHOBHA
Middle Name:S
Last Name:IYENGAR
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 1:1371 SANDHURST LN
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-2789
Mailing Address - Country:US
Mailing Address - Phone:815-547-5007
Mailing Address - Fax:
Practice Address - Street 1:2186 UNIT 1 NORTH STATE STREET
Practice Address - Street 2:203
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-3918
Practice Address - Country:US
Practice Address - Phone:815-547-5007
Practice Address - Fax:815-547-7338
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036094136207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094136Medicaid
IL036094136Medicaid
ILP00322993Medicare PIN
ILK12539Medicare PIN
IL210379Medicare PIN
ILDE8901Medicare PIN