Provider Demographics
NPI:1538388806
Name:SHAPIRO, JERROLD E (MD)
Entity type:Individual
Prefix:
First Name:JERROLD
Middle Name:E
Last Name:SHAPIRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6374 N LINCOLN AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-1283
Mailing Address - Country:US
Mailing Address - Phone:773-588-5900
Mailing Address - Fax:773-588-5775
Practice Address - Street 1:6374 N LINCOLN AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-1283
Practice Address - Country:US
Practice Address - Phone:773-588-5900
Practice Address - Fax:773-588-5775
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036042757207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036042757Medicaid
IL036042757Medicaid
IL491130Medicare PIN