Provider Demographics
NPI:1699033761
Name:SHAH, AMISHA (DO)
Entity Type:Individual
Prefix:
First Name:AMISHA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 W. 95TH ST.
Mailing Address - Street 2:STE 101
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:312-609-0300
Mailing Address - Fax:
Practice Address - Street 1:4400 W 95TH ST STE 101
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2655
Practice Address - Country:US
Practice Address - Phone:312-609-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-26
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-138213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine