Provider Demographics
NPI:1558675942
Name:SHAH, PUJA (OD)
Entity type:Individual
Prefix:
First Name:PUJA
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 1:3220 W ARMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3797
Mailing Address - Country:US
Mailing Address - Phone:773-661-6615
Mailing Address - Fax:773-698-7408
Practice Address - Street 1:3220 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3797
Practice Address - Country:US
Practice Address - Phone:773-661-6615
Practice Address - Fax:773-698-7408
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.010366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010366Medicaid