Provider Demographics
NPI:1750626081
Name:WARDA, SHAMSHOUN (CSA)
Entity type:Individual
Prefix:MR
First Name:SHAMSHOUN
Middle Name:
Last Name:WARDA
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:SAM
Other - Middle Name:
Other - Last Name:WARDA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSA
Mailing Address - Street 1:2740 W FOSTER AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-8804
Practice Address - Street 1:5145 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3661
Practice Address - Country:US
Practice Address - Phone:773-878-8200
Practice Address - Fax:773-271-5090
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-27
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000353246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant