Provider Demographics
NPI:1669784872
Name:UDDIN, SHAHAAB (MD)
Entity type:Individual
Prefix:
First Name:SHAHAAB
Middle Name:
Last Name:UDDIN
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 1:3 ERIE CT
Mailing Address - Street 2:SUITE L-700
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2519
Mailing Address - Country:US
Mailing Address - Phone:708-763-1222
Mailing Address - Fax:708-763-1471
Practice Address - Street 1:1850 STATE ST
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4990
Practice Address - Country:US
Practice Address - Phone:812-944-7701
Practice Address - Fax:812-981-6505
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-06
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073189B208M00000X
IL036131145208M00000X
IL125058873207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036131145OtherSTATE LICENSE
IN201187680Medicaid