Provider Demographics
NPI:1770744476
Name:MATHEN, SHAUN KURIAKOSE (DO)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:KURIAKOSE
Last Name:MATHEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HEALTH SERVICES DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-9647
Mailing Address - Country:US
Mailing Address - Phone:815-754-0300
Mailing Address - Fax:815-754-0400
Practice Address - Street 1:8 HEALTH SERVICES DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-9647
Practice Address - Country:US
Practice Address - Phone:815-754-0300
Practice Address - Fax:815-754-0400
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119224207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL2305006OtherMEDICARE INDIVIDUAL
IL036119224Medicaid
ILIL6309OtherMEDICARE GROUP
ILIL6309OtherMEDICARE GROUP
ILIL2305006Medicare PIN
ILP01051492Medicare UPIN