Provider Demographics
NPI:1902133937
Name:SHAH, ANSUYA (MD)
Entity Type:Individual
Prefix:DR
First Name:ANSUYA
Middle Name:
Last Name:SHAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1146 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1310
Mailing Address - Country:US
Mailing Address - Phone:708-366-2707
Mailing Address - Fax:
Practice Address - Street 1:1146 PARK AVE
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1310
Practice Address - Country:US
Practice Address - Phone:708-366-2707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
036054371261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care