Provider Demographics
NPI:1508076555
Name:SHAH, JESIKA (MD)
Entity Type:Individual
Prefix:
First Name:JESIKA
Middle Name:
Last Name:SHAH
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 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7915
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:6809 122ND AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7335
Practice Address - Country:US
Practice Address - Phone:262-654-8633
Practice Address - Fax:262-654-5467
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI70515-20208000000X
NY0027002080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1508076555Medicaid
NY02851398Medicaid