MEDICARE: DR. SHAUN T ITTIARA M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	036127360	IL
2	207WX0107X	Retina Specialist (Ophthalmology) Physician	036.127360	IL

General Provider Information

NPI Number	:	1992995542
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHAUN T ITTIARA M.D.

Provider Business Mailing Address
First Line	:	PO BOX 166516
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-6516
Country	:	US
Telephone Number	:	312-567-2795
Fax Number	:	800-707-4890

Provider Business Practice Location Address
First Line	:	2600 S MICHIGAN AVE STE 212
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60616-2859
Country	:	US
Telephone Number	:	312-567-2795
Fax Number	:	800-707-4890

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/05/2023

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