Provider Demographics
NPI:1851590343
Name:SHAH, ANKUR MANILAL (MD)
Entity Type:Individual
Prefix:DR
First Name:ANKUR
Middle Name:MANILAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-7015
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:1230 CENTRE WEST DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-2173
Practice Address - Country:US
Practice Address - Phone:217-321-2020
Practice Address - Fax:217-321-2026
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.125518207W00000X
WI55779207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1851590343Medicaid
IL036125518 2Medicaid
WI0264580002Medicare NSC
ILF400296320Medicare PIN
WI1588963508Medicare NSC
WI0264580001Medicare NSC
WI1427347822Medicare NSC