Healthcare Provider Details

I. General information

NPI: 1821440751
Provider Name (Legal Business Name): DAVID SHIYU ZHU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2016
Last Update Date: 07/15/2022
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4802 S STATE ROUTE 159
GLEN CARBON IL
62034-1904
US

IV. Provider business mailing address

9468 GREYSTONE PKWY
BRECKSVILLE OH
44141-2942
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-4388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number125.069442
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number036.161379
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: