Provider Demographics
NPI:1417966789
Name:SHAH, SUDHA V (MD)
Entity type:Individual
Prefix:
First Name:SUDHA
Middle Name:V
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1516 W DEVON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60660-1314
Mailing Address - Country:US
Mailing Address - Phone:773-465-7889
Mailing Address - Fax:773-465-7615
Practice Address - Street 1:1516 W DEVON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-1314
Practice Address - Country:US
Practice Address - Phone:773-465-7889
Practice Address - Fax:773-465-7615
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360608952080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036060895Medicaid
IL036060895Medicaid