Provider Demographics
NPI:1154323574
Name:SHAH, DIPAK S (MD)
Entity Type:Individual
Prefix:DR
First Name:DIPAK
Middle Name:S
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DIPAK
Other - Middle Name:S
Other - Last Name:SHAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:615 VALLEY VIEW DR.
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-6180
Mailing Address - Country:US
Mailing Address - Phone:309-762-1072
Mailing Address - Fax:309-762-1094
Practice Address - Street 1:615 VALLEY VIEW DR.
Practice Address - Street 2:SUITE 202
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-6180
Practice Address - Country:US
Practice Address - Phone:309-762-1072
Practice Address - Fax:309-762-1094
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0540792085R0202X
IA264292085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR03571Medicare PIN
IAI0849Medicare PIN
ILL34886Medicare PIN
B18091Medicare UPIN