Provider Demographics
NPI:1235172248
Name:SHUKLA, PREM C (MD)
Entity Type:Individual
Prefix:DR
First Name:PREM
Middle Name:C
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 1:3506 SPEEDWAY APT 204
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78705-1551
Mailing Address - Country:US
Mailing Address - Phone:800-342-2898
Mailing Address - Fax:
Practice Address - Street 1:265 BROOKVIEW CENTRE WAY STE 400
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4052
Practice Address - Country:US
Practice Address - Phone:800-342-2898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6929207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0065PTOtherBCBS
TX043985335Medicaid
TXP01157825OtherRAILROAD MEDICARE
TXA79357Medicare UPIN
TX043985335Medicaid