Provider Demographics
NPI:1720035009
Name:SHAH, MIR JAFAR (MD)
Entity Type:Individual
Prefix:
First Name:MIR
Middle Name:JAFAR
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 226
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA FIELDS
Mailing Address - State:IL
Mailing Address - Zip Code:60461-0226
Mailing Address - Country:US
Mailing Address - Phone:708-709-2175
Mailing Address - Fax:
Practice Address - Street 1:COMPRREHENSIVE CANCER CENTER
Practice Address - Street 2:3900 BURKE DRIVE
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461
Practice Address - Country:US
Practice Address - Phone:709-747-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
IL036-0488692085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036048869Medicaid
F400308371OtherMEDICARE INDIVIDUAL PTAN FOR SPECIALTY PHYSICIANS
IL493391Medicare ID - Type Unspecified
ILL01822Medicare UPIN