Provider Demographics
NPI:1629212782
Name:SHAH, UMANG M (MD)
Entity Type:Individual
Prefix:
First Name:UMANG
Middle Name:M
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-385-8780
Mailing Address - Fax:
Practice Address - Street 1:2801 W. KINNICKINNIC RIVER PARKWAY
Practice Address - Street 2:SUITE 570
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-385-8780
Practice Address - Fax:414-385-8781
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI603682084N0600X
WI60368202084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100033887Medicaid