Provider Demographics
NPI:1013370204
Name:SHUKLA, MEDHA
Entity Type:Individual
Prefix:
First Name:MEDHA
Middle Name:
Last Name:SHUKLA
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 1:11175 CAMPUS ST RM A1111
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1700
Mailing Address - Country:US
Mailing Address - Phone:909-558-8142
Mailing Address - Fax:
Practice Address - Street 1:25845 BARTON RD STE 101
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-5300
Practice Address - Country:US
Practice Address - Phone:909-558-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1629442080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology