Healthcare Provider Details

I. General information

NPI: 1295186872
Provider Name (Legal Business Name): RAVI SHAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2016
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2640 183RD ST
HOMEWOOD IL
60430-2914
US

IV. Provider business mailing address

2855 GRAMERCY ST STE 400
HOUSTON TX
77025-1697
US

V. Phone/Fax

Practice location:
  • Phone: 708-798-6633
  • Fax: 708-798-6790
Mailing address:
  • Phone: 713-668-6828
  • Fax: 713-668-3823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036172784
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberS6038
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: