Provider Demographics
NPI:1538417498
Name:PUJA SHAH O.D, P.C
Entity type:Organization
Organization Name:PUJA SHAH O.D, P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PUJA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAH
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:773-661-6615
Mailing Address - Street 1:3220 W ARMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-3797
Mailing Address - Country:US
Mailing Address - Phone:773-661-6615
Mailing Address - Fax:773-698-7408
Practice Address - Street 1:3220 W ARMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-3797
Practice Address - Country:US
Practice Address - Phone:773-661-6615
Practice Address - Fax:773-698-7408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010366152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046.010366Medicaid