Provider Demographics
NPI:1275517211
Name:SHAH, SUNIL (DO)
Entity Type:Individual
Prefix:
First Name:SUNIL
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7641 NEWFIELD LN
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60487-5539
Mailing Address - Country:US
Mailing Address - Phone:708-423-7424
Mailing Address - Fax:708-423-7428
Practice Address - Street 1:4647 W 103RD ST
Practice Address - Street 2:SUITE 1-I
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4779
Practice Address - Country:US
Practice Address - Phone:708-423-7424
Practice Address - Fax:708-423-7428
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-02
Last Update Date:2014-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105759207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH66887Medicare UPIN