Provider Demographics
NPI:1407138324
Name:SHAH, DIPAK
Entity Type:Individual
Prefix:DR
First Name:DIPAK
Middle Name:
Last Name:SHAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 LARAMIE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-3465
Mailing Address - Country:US
Mailing Address - Phone:847-724-5155
Mailing Address - Fax:
Practice Address - Street 1:5158 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2521
Practice Address - Country:US
Practice Address - Phone:773-907-8490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-16
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051032925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist