Healthcare Provider Details

I. General information

NPI: 1134481211
Provider Name (Legal Business Name): BIRVA K SHAH O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BIRVA A KADAKIA OD

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10436 SOUTHWEST HWY SUITE 101
CHICAGO RIDGE IL
60415-2282
US

IV. Provider business mailing address

4684 DEPT
CAROL STREAM IL
60122-4684
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-4192
  • Fax: 708-952-0329
Mailing address:
  • Phone: 708-423-4192
  • Fax: 708-952-0329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046010543
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code152WP0200X
TaxonomyPediatric Optometrist
License Number046010543
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: