Provider Demographics
NPI:1982746848
Name:SHELADIA, KETAN K (OD)
Entity Type:Individual
Prefix:DR
First Name:KETAN
Middle Name:K
Last Name:SHELADIA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5109 S PULASKI RD
Mailing Address - Street 2:UNIT D
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-4219
Mailing Address - Country:US
Mailing Address - Phone:773-284-9844
Mailing Address - Fax:773-284-9827
Practice Address - Street 1:5109 S PULASKI RD
Practice Address - Street 2:UNIT D
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4219
Practice Address - Country:US
Practice Address - Phone:773-284-9844
Practice Address - Fax:773-284-9827
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2013-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009646152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL221691OtherEYEMED