1164985883 NPI number — DR. DEEP N SHAH DPM, MBA

Table of content: DR. DEEP N SHAH DPM, MBA (NPI 1164985883)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164985883 NPI number — DR. DEEP N SHAH DPM, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAH
Provider First Name:
DEEP
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM, MBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164985883
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1004 TUSCANY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STREAMWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60107-4529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-330-7689
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
183 W 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELMHURST
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60126-2815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-530-3338
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  016.005976 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0131X , with the licence number: 016.005976 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213EP1101X , with the licence number: 016.005976 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ER0200X , with the licence number: 016.005976 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0000X , with the licence number: 016.005976 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)