Provider Demographics
NPI:1174968846
Name:SHAH, KRUPA MAHESH
Entity type:Individual
Prefix:
First Name:KRUPA
Middle Name:MAHESH
Last Name:SHAH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 N CONVENT ST
Mailing Address - Street 2:STE 1
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 N CONVENT ST STE 1
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1081
Practice Address - Country:US
Practice Address - Phone:815-937-5200
Practice Address - Fax:815-937-2063
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139908207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology