Provider Demographics
NPI:1972672715
Name:SHAH, ASHOK C (MD)
Entity Type:Individual
Prefix:MR
First Name:ASHOK
Middle Name:C
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 1:1624 W MONTROSE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613
Mailing Address - Country:US
Mailing Address - Phone:773-769-3338
Mailing Address - Fax:773-769-5568
Practice Address - Street 1:1624 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613
Practice Address - Country:US
Practice Address - Phone:773-769-3338
Practice Address - Fax:773-769-5568
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064449207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036064449Medicaid
721850Medicare ID - Type Unspecified
IL036064449Medicaid