Healthcare Provider Details

I. General information

NPI: 1619362795
Provider Name (Legal Business Name): KARTHIK SHASTRI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2015
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 PATRIOT BLVD
GLENVIEW IL
60026-8039
US

IV. Provider business mailing address

2701 PATRIOT BLVD
GLENVIEW IL
60026-8039
US

V. Phone/Fax

Practice location:
  • Phone: 847-724-4536
  • Fax: 847-509-0536
Mailing address:
  • Phone: 847-724-4536
  • Fax: 847-509-0536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number60856
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number60856
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number63652
License Number StateNY
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036157688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: