Provider Demographics
NPI:1033679493
Name:AMIN, SHIVAM VIPUL (MD)
Entity Type:Individual
Prefix:
First Name:SHIVAM
Middle Name:VIPUL
Last Name:AMIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 N 87TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4812
Mailing Address - Country:US
Mailing Address - Phone:414-955-2020
Mailing Address - Fax:414-955-6300
Practice Address - Street 1:925 N 87TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4812
Practice Address - Country:US
Practice Address - Phone:414-955-2020
Practice Address - Fax:414-955-6300
Is Sole Proprietor?:No
Enumeration Date:2019-03-21
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125073564207W00000X
WI81518207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology