Basic Information
| Provider Information | |||||||||
| NPI: | 1902255656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAH | ||||||||
| FirstName: | NISHITH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 450 CLARKSON AVE | ||||||||
| Address2: | BOX 1262 | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112032012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182708867 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3401 N PERRYVILLE RD | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611148011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159713610 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2016 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036.150303 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.