Healthcare Provider Details

I. General information

NPI: 1306830583
Provider Name (Legal Business Name): SHAUKAT JAMAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2005
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4436
US

IV. Provider business mailing address

478 PENNSYLVANIA AVE STE 101
GLEN ELLYN IL
60137-4436
US

V. Phone/Fax

Practice location:
  • Phone: 630-545-2887
  • Fax: 630-682-5276
Mailing address:
  • Phone: 630-545-2887
  • Fax: 630-682-5276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: