Healthcare Provider Details

I. General information

NPI: 1124003462
Provider Name (Legal Business Name): VANDNA A SHAH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 10/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3530 W 159TH ST
MARKHAM IL
60428-4047
US

IV. Provider business mailing address

3530 W 159TH ST
MARKHAM IL
60428-4047
US

V. Phone/Fax

Practice location:
  • Phone: 708-333-3318
  • Fax:
Mailing address:
  • Phone: 708-333-3318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036071087
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: