Provider Demographics
NPI:1922767078
Name:SHASHIDHAR, SANJANA (OD)
Entity type:Individual
Prefix:
First Name:SANJANA
Middle Name:
Last Name:SHASHIDHAR
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 W LAKE COOK RD STE C
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-1970
Mailing Address - Country:US
Mailing Address - Phone:847-459-6060
Mailing Address - Fax:847-459-7575
Practice Address - Street 1:1120 W LAKE COOK RD
Practice Address - Street 2:
Practice Address - City:BUFFALO GROVE
Practice Address - State:IL
Practice Address - Zip Code:60089-1970
Practice Address - Country:US
Practice Address - Phone:847-459-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-15
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021048811152W00000X, 152WC0802X, 152WP0200X, 152WV0400X
IL046011695152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
No152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WV0400XEye and Vision Services ProvidersOptometristVision Therapy