Provider Demographics
NPI:1235179375
Name:SHAKULA, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:SHAKULA
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 1:12801 BOULTER ST
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9134
Mailing Address - Country:US
Mailing Address - Phone:801-571-0423
Mailing Address - Fax:801-571-0081
Practice Address - Street 1:9720 S 1300 E
Practice Address - Street 2:W120
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-3712
Practice Address - Country:US
Practice Address - Phone:801-571-0423
Practice Address - Fax:801-571-0081
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1574601205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics