Healthcare Provider Details

I. General information

NPI: 1992714117
Provider Name (Legal Business Name): SHAILAJA POTDAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8321 W. GOLD RD.
NILES IL
60714
US

IV. Provider business mailing address

6301 N WESTERN AVE
CHICAGO IL
60659-2009
US

V. Phone/Fax

Practice location:
  • Phone: 847-720-3511
  • Fax: 847-720-3511
Mailing address:
  • Phone: 800-597-5077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036159053
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number196775
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: