Healthcare Provider Details

I. General information

NPI: 1649268780
Provider Name (Legal Business Name): VIBHAKAR SHANTILAL SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 S GREENLEAF ST SUITE NO. 109
GURNEE IL
60031-5705
US

IV. Provider business mailing address

222 S GREENLEAF ST SUITE NO. 109
GURNEE IL
60031-5705
US

V. Phone/Fax

Practice location:
  • Phone: 847-249-0167
  • Fax: 847-249-0717
Mailing address:
  • Phone: 847-249-0167
  • Fax: 847-249-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036053632
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: