Provider Demographics
NPI:1962430272
Name:SHAH, MAYANK KANAIYALAL (MD)
Entity type:Individual
Prefix:DR
First Name:MAYANK
Middle Name:KANAIYALAL
Last Name:SHAH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:7435 W TALCOTT AVE
Mailing Address - Street 2:SUITE 182
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3707
Mailing Address - Country:US
Mailing Address - Phone:773-792-5154
Mailing Address - Fax:773-594-7975
Practice Address - Street 1:7435 W TALCOTT AVE
Practice Address - Street 2:SUITE 182
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3707
Practice Address - Country:US
Practice Address - Phone:773-792-5154
Practice Address - Fax:773-594-7975
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036106149207Q00000X, 207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036106149Medicaid
ILH72274Medicare UPIN
IL94249Medicare ID - Type Unspecified