Healthcare Provider Details

I. General information

NPI: 1639223928
Provider Name (Legal Business Name): MOHAMMAD R SHAKER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 03/18/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 ESSINGTON RD STE 101
JOLIET IL
60435-8447
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 888-938-3838
  • Fax: 888-919-1083
Mailing address:
  • Phone: 888-720-2012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number48503020
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number48503
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number036-105323
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: