Provider Demographics
NPI:1003119694
Name:SHAH VISION CONSULTANTS INC
Entity Type:Organization
Organization Name:SHAH VISION CONSULTANTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:PRAYAG
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-315-9358
Mailing Address - Street 1:575 S PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2530
Mailing Address - Country:US
Mailing Address - Phone:815-315-9358
Mailing Address - Fax:815-315-9358
Practice Address - Street 1:575 S PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2530
Practice Address - Country:US
Practice Address - Phone:815-315-9358
Practice Address - Fax:815-315-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-21
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3076Medicare PIN