Provider Demographics
NPI:1407825011
Name:SHAH, SUMIN (DO)
Entity Type:Individual
Prefix:
First Name:SUMIN
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 1:1012 95TH ST
Mailing Address - Street 2:SUITE 7
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5041
Mailing Address - Country:US
Mailing Address - Phone:630-312-7865
Mailing Address - Fax:630-312-7092
Practice Address - Street 1:1012 95TH ST
Practice Address - Street 2:STE 7
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5041
Practice Address - Country:US
Practice Address - Phone:630-428-3828
Practice Address - Fax:630-428-3848
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036103782207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036103782Medicaid
IL989190Medicare ID - Type Unspecified
IL036103782Medicaid