Healthcare Provider Details

I. General information

NPI: 1164985883
Provider Name (Legal Business Name): DEEP N SHAH DPM, MBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 W 1ST ST
ELMHURST IL
60126-2815
US

IV. Provider business mailing address

1004 TUSCANY DR
STREAMWOOD IL
60107-4529
US

V. Phone/Fax

Practice location:
  • Phone: 630-530-3338
  • Fax:
Mailing address:
  • Phone: 518-330-7689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016.005976
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number016.005976
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number016.005976
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number016.005976
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number016.005976
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: