Provider Demographics
NPI:1669888491
Name:SHAH, RAJU KIRTIKUMAR (MD)
Entity type:Individual
Prefix:
First Name:RAJU
Middle Name:KIRTIKUMAR
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4461 PROGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1109
Mailing Address - Country:US
Mailing Address - Phone:815-223-9683
Mailing Address - Fax:815-223-9683
Practice Address - Street 1:5101 WILLOW SPRINGS RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2600
Practice Address - Country:US
Practice Address - Phone:708-245-8900
Practice Address - Fax:708-245-5604
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143438207QG0300X
IL125065796390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program