Healthcare Provider Details

I. General information

NPI: 1760480750
Provider Name (Legal Business Name): JOHN ANDREW SHOUDEL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2005
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2070 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

747 N RUTLEDGE ST
SPRINGFIELD IL
62702-6700
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-6228
  • Fax: 217-698-7241
Mailing address:
  • Phone: 217-652-3816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberIL016004443
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: