Provider Demographics
NPI:1851684476
Name:SHAH, MANTHAN RAJESH (MD)
Entity Type:Individual
Prefix:DR
First Name:MANTHAN
Middle Name:RAJESH
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:7447 W TALCOTT AVE
Mailing Address - Street 2:STE 345
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3714
Mailing Address - Country:US
Mailing Address - Phone:708-216-3833
Mailing Address - Fax:708-216-2778
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:LOYOLA OUTPATIENT CENTER 4200
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-3833
Practice Address - Fax:708-216-2778
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2021-12-30
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Provider Licenses
StateLicense IDTaxonomies
IL036140120207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid