Provider Demographics
NPI:1497843460
Name:SHAH, JAGDISH RATILAL (MD)
Entity Type:Individual
Prefix:
First Name:JAGDISH
Middle Name:RATILAL
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 1:1722 MIDWEST CLUB
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523
Mailing Address - Country:US
Mailing Address - Phone:314-733-2555
Mailing Address - Fax:773-521-9566
Practice Address - Street 1:1231 W ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60688
Practice Address - Country:US
Practice Address - Phone:312-733-2555
Practice Address - Fax:312-733-2555
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14024Medicare UPIN
682980Medicare ID - Type Unspecified