Provider Demographics
NPI:1467473231
Name:SHAH, PRAVIN S (MD,)
Entity Type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:S
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400E GOLF RD 222
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1252
Mailing Address - Country:US
Mailing Address - Phone:847-391-6360
Mailing Address - Fax:
Practice Address - Street 1:1400E GOLF RD 222
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1252
Practice Address - Country:US
Practice Address - Phone:847-391-6360
Practice Address - Fax:847-391-6360
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036055437207Q00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD93834Medicare UPIN
IL663390Medicare ID - Type Unspecified