Provider Demographics
NPI:1770670408
Name:SHAH, JAYMIN R (DO)
Entity Type:Individual
Prefix:DR
First Name:JAYMIN
Middle Name:R
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 YORK CT
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-3371
Mailing Address - Country:US
Mailing Address - Phone:608-756-6049
Mailing Address - Fax:
Practice Address - Street 1:1000 MINERAL POINT AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53548-2940
Practice Address - Country:US
Practice Address - Phone:847-837-0252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123633207LP2900X
WI50065-21207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1770670408Medicaid
IL036123633 1Medicaid
WISHAHJAYOtherMERCYCARE INSURANCE
WI1770670408Medicaid
IL214660055Medicare PIN