Provider Demographics
NPI:1568509008
Name:SHAH, KAVITA
Entity Type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N COUNTY FARM RD
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3988
Mailing Address - Country:US
Mailing Address - Phone:630-712-4966
Mailing Address - Fax:
Practice Address - Street 1:111 N COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3977
Practice Address - Country:US
Practice Address - Phone:630-682-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0992812084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL100273730Medicaid