Provider Demographics
NPI:1861252942
Name:SHIBU, SHERRY (DO)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:SHIBU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3231 EUCLID AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3466
Mailing Address - Country:US
Mailing Address - Phone:877-834-7264
Mailing Address - Fax:
Practice Address - Street 1:3231 EUCLID AVE FL 5
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3466
Practice Address - Country:US
Practice Address - Phone:877-834-7264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-19
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL125.083400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program