Provider Demographics
NPI:1053383737
Name:JAFRY, SHAHINA H (MD)
Entity type:Individual
Prefix:
First Name:SHAHINA
Middle Name:H
Last Name:JAFRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:526 W. STATE STREET
Mailing Address - Street 2:PO BOX 813
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-1214
Mailing Address - Country:US
Mailing Address - Phone:815-968-9300
Mailing Address - Fax:815-968-5314
Practice Address - Street 1:526 W. STATE STREET
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-1214
Practice Address - Country:US
Practice Address - Phone:815-968-9300
Practice Address - Fax:815-968-5314
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2011-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361055702084P0800X
IL361055702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105570Medicaid
ILL89511Medicare PIN
IL036105570Medicaid
ILH52348Medicare PIN