Provider Demographics
NPI:1902032014
Name:SHAH, PRERAK RAJESHKUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:PRERAK
Middle Name:RAJESHKUMAR
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 1:213 N RACINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1644
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:
Practice Address - Street 1:5818 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-2607
Practice Address - Country:US
Practice Address - Phone:219-237-5160
Practice Address - Fax:219-321-1935
Is Sole Proprietor?:No
Enumeration Date:2009-06-03
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051560207Q00000X
IN01076066A207Q00000X
IL036-136289207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine