Provider Demographics
NPI:1083957856
Name:SHUKLA, PANCHANAN (MD)
Entity Type:Individual
Prefix:
First Name:PANCHANAN
Middle Name:
Last Name:SHUKLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3950 COLORADO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0240
Mailing Address - Country:US
Mailing Address - Phone:312-554-9644
Mailing Address - Fax:
Practice Address - Street 1:1011 BALDWIN PARK BLVD
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-5806
Practice Address - Country:US
Practice Address - Phone:626-851-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-31
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA142128207P00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine