Provider Demographics
NPI:1700813771
Name:BANSORE, SHAMITA V (MD)
Entity Type:Individual
Prefix:
First Name:SHAMITA
Middle Name:V
Last Name:BANSORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HIGHLAND AVE
Mailing Address - Street 2:TOWER 1 SUITE 2F
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1552
Mailing Address - Country:US
Mailing Address - Phone:630-852-3762
Mailing Address - Fax:630-852-4087
Practice Address - Street 1:3825 HIGHLAND AVE
Practice Address - Street 2:TOWER 1 SUITE 2F
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1552
Practice Address - Country:US
Practice Address - Phone:630-852-3762
Practice Address - Fax:630-852-4087
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036107104207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036107104Medicaid
K35651Medicare UPIN
ILI30050Medicare UPIN