Healthcare Provider Details

I. General information

NPI: 1902032014
Provider Name (Legal Business Name): PRERAK RAJESHKUMAR SHAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W 63RD ST
CHICAGO IL
60621-1902
US

IV. Provider business mailing address

PO BOX 746715
ATLANTA GA
30374-6715
US

V. Phone/Fax

Practice location:
  • Phone: 773-377-7304
  • Fax:
Mailing address:
  • Phone: 773-377-7304
  • Fax: 773-634-7965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-136289
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01076066A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051560
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: