Provider Demographics
NPI:1235636309
Name:AMTUL SHAFI, UNKNOWN
Entity Type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:AMTUL SHAFI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 250
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3861
Mailing Address - Country:US
Mailing Address - Phone:312-942-5000
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 250
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3861
Practice Address - Country:US
Practice Address - Phone:312-942-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA10331390200000X
IL160966207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program