Provider Demographics
NPI:1902149982
Name:SHAH, MAULIN G (DO)
Entity type:Individual
Prefix:
First Name:MAULIN
Middle Name:G
Last Name:SHAH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 WATTERS DR
Mailing Address - Street 2:
Mailing Address - City:DWIGHT
Mailing Address - State:IL
Mailing Address - Zip Code:60420-1280
Mailing Address - Country:US
Mailing Address - Phone:815-584-4334
Mailing Address - Fax:815-584-4364
Practice Address - Street 1:107 WATTERS DR
Practice Address - Street 2:
Practice Address - City:DWIGHT
Practice Address - State:IL
Practice Address - Zip Code:60420
Practice Address - Country:US
Practice Address - Phone:815-584-4334
Practice Address - Fax:815-584-4364
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-28
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141076207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine