Provider Demographics
NPI:1801310313
Name:SHAH, NIKITA (OD)
Entity type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 SOUTHGATE DR
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-2955
Mailing Address - Country:US
Mailing Address - Phone:847-863-0035
Mailing Address - Fax:
Practice Address - Street 1:62 OAKBROOK CTR
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-1810
Practice Address - Country:US
Practice Address - Phone:630-243-5224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-27
Last Update Date:2017-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011139152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist