Provider Demographics
NPI:1518986512
Name:SHANTHAPPA, VINODA (MD)
Entity type:Individual
Prefix:
First Name:VINODA
Middle Name:
Last Name:SHANTHAPPA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VINODA
Other - Middle Name:
Other - Last Name:VINODA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:METHODIST MEDICAL CTR
Mailing Address - Street 2:221.NE GLEN OAK AVE
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61636-0002
Mailing Address - Country:US
Mailing Address - Phone:309-672-5729
Mailing Address - Fax:309-672-5772
Practice Address - Street 1:METHODIST MEDICAL CTR
Practice Address - Street 2:221.NE GLEN OAK AVE
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-0002
Practice Address - Country:US
Practice Address - Phone:309-672-5729
Practice Address - Fax:309-672-5772
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2009-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36114697207R00000X
IL036114697208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3711361916002Medicaid
IL036114697OtherIL LICENSE
IL036114697OtherIL LICENSE