MEDICARE: SHIVANI THAKKAR SAMPAT OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046.012066	IL

General Provider Information

NPI Number	:	1679427033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIVANI THAKKAR SAMPAT OD

Provider Business Mailing Address
First Line	:	1350 W 18TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3148
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1350 W 18TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60608-3148
Country	:	US
Telephone Number	:	312-261-5503
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2026
Last Update Date	:	02/23/2026

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