Provider Demographics
NPI:1700047016
Name:SHETH, AVANI
Entity Type:Individual
Prefix:
First Name:AVANI
Middle Name:
Last Name:SHETH
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 1:1431 N WESTERN AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-1797
Mailing Address - Country:US
Mailing Address - Phone:312-633-5841
Mailing Address - Fax:312-491-5485
Practice Address - Street 1:1431 N WESTERN AVE
Practice Address - Street 2:SUITE 406
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60622-1797
Practice Address - Country:US
Practice Address - Phone:312-633-5841
Practice Address - Fax:312-491-5020
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-19
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136479207QA0401X
NY249068207Q00000X
WAMD60257660207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036136479Medicaid
8908875Medicare UPIN