Provider Demographics
NPI:1932633849
Name:SHAH, KUSHAL DEEPAK (MD)
Entity Type:Individual
Prefix:DR
First Name:KUSHAL
Middle Name:DEEPAK
Last Name:SHAH
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 1:101 E 75TH ST STE 105
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60565-1411
Mailing Address - Country:US
Mailing Address - Phone:630-933-1700
Mailing Address - Fax:630-933-6240
Practice Address - Street 1:101 E 75TH ST STE 105
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60565-1411
Practice Address - Country:US
Practice Address - Phone:630-933-1700
Practice Address - Fax:630-933-6240
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036152184207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program