Provider Demographics
NPI:1881600187
Name:SHAH, INDIRA
Entity type:Individual
Prefix:
First Name:INDIRA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMITTANCE DR DEPT 1704
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1704
Mailing Address - Country:US
Mailing Address - Phone:727-823-2188
Mailing Address - Fax:
Practice Address - Street 1:2526 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2353
Practice Address - Country:US
Practice Address - Phone:773-929-7410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36057975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL31600190OtherBCBS
110008973OtherRAILROAD MEDICARE
IL658661001Medicare PIN
110008973OtherRAILROAD MEDICARE