Provider Demographics
NPI:1720072184
Name:SHAH, PRAYAG D (OD)
Entity type:Individual
Prefix:
First Name:PRAYAG
Middle Name:D
Last Name:SHAH
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 1:575 S PERRYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2530
Mailing Address - Country:US
Mailing Address - Phone:815-315-9358
Mailing Address - Fax:815-397-4684
Practice Address - Street 1:575 S PERRYVILLE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2530
Practice Address - Country:US
Practice Address - Phone:815-315-9358
Practice Address - Fax:815-397-4684
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2014-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046009516Medicaid
U93231Medicare UPIN
ILL95301Medicare ID - Type Unspecified