Provider Demographics
NPI:1164985883
Name:SHAH, DEEP N (DPM, MBA)
Entity Type:Individual
Prefix:
First Name:DEEP
Middle Name:N
Last Name:SHAH
Suffix:
Gender:M
Credentials:DPM, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 TUSCANY DR
Mailing Address - Street 2:
Mailing Address - City:STREAMWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60107-4529
Mailing Address - Country:US
Mailing Address - Phone:518-330-7689
Mailing Address - Fax:
Practice Address - Street 1:3333 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:NORTH CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60064-3037
Practice Address - Country:US
Practice Address - Phone:847-473-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-09
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016.005976213EP1101X, 213ER0200X, 213ES0000X, 213ES0131X, 213ES0103X
PASC007033213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiology
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery