Healthcare Provider Details

I. General information

NPI: 1407162530
Provider Name (Legal Business Name): SHILPA MEHTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W POLK ST
CHICAGO IL
60612-3723
US

IV. Provider business mailing address

100 E 14TH ST APT 1001
CHICAGO IL
60605-3666
US

V. Phone/Fax

Practice location:
  • Phone: 312-864-6000
  • Fax:
Mailing address:
  • Phone: 847-596-0356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125053959
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-128502
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: