Provider Demographics
NPI:1144269044
Name:SHUKLA, LATA R (MD)
Entity type:Individual
Prefix:DR
First Name:LATA
Middle Name:R
Last Name:SHUKLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7220 E VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7220 E VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4068
Practice Address - Country:US
Practice Address - Phone:812-473-8986
Practice Address - Fax:812-471-6692
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01052377A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200319540Medicaid
IN000000487305OtherANTHEM PIN
IN237890OtherMEDICARE GROUP
IN200829650DOtherMEDICAID GROUP
IN200319540Medicaid